Unnecessary blood tests for patients with miscarriages

Recurrent pregnancy losses ( recurrent miscarriages) are one of reproductive medicine's most frustrating problems.

Lots of doctors order a panel of expensive blood tests to find out the reason for the miscarriages, so they can treat it.

However, the ABIM Foundation has shown that these tests are useless.

Read more at http://consumerhealthchoices.org/catalog/blood-tests-miscarriage-risk-smfm/

Read more at http://www.drmalpani.com/knowledge-center/articles/recurrentabortion

Need 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 !

The problem with the mindless implementation of the PCPNDT Act

The Surat health officer said - " We have fixed a target to reach 1,000 girls against 1,000 boys."

http://indianexpress.com/article/cities/ahmedabad/surat-sex-ratio-has-improved-in-2014-15-says-crs-data-4443680/


This is exactly the fear doctors had when the PCPNDT Act was passed. The normal sex ratio at birth is 950 girls to 1000 boys. However, in their over-zealousness to prove that they are working hard, government health officials have started setting mindless "targets" and made a mockery of medical facts ! They will continue barking up the wrong tree, because of their ignorance.

Why I admire women who are willing to go through a second IVF cycle.

I'm an IVF specialist and I do hundreds of IVF cycles every year. I've treated thousands of women, and I continue admire women who are willing to go through a second IVF cycle. Now they may have done the first IVF cycle at some other clinic; the cycle may have failed ; or they may have got pregnant and miscarried or ended up with an ectopic. But, the fact that they have the courage to try once more means they actually have a lot of guts and I admire them for this.

There's a lot of suspense and uncertainty involved in any IVF cycle. You never know if it's going to work or not , and you continue hoping that you're going to get lucky - if not the first time, then at least the second ! And isn't the third time considered to be lucky ?

Dealing with this uncertainty can be nerve wrecking even for me as an IVF doctor , so I can imagine how much worse it must be for patients who have so much riding on an IVF cycle.

Yet , in spite of the fact that they know they have to make repeated visits to the clinic; take injections daily; get their private parts prodded for regular ultrasound scans; and get poked for blood tests till they start feeling like a pin-cushion, they still have the guts and the stamina to start a new cycle, without ever being sure whether it's going to work or not.

To add insult to injury, they have to wait for hours on end to see the doctor and get their blood results; spend tons of money on chasing what seems to be a mirage; and be forced to lie in bed in the hope that this will get their embryos to stick.  Having to do all this just in order to get pregnant - a goal which millions of other women achieve effortlessly in their bedrooms - eats into their self esteem ; and impacts their career and their marriage.

In spite of knowing the pain and heartache which an IVF cycle involves, they are willing to give it a second and a third shot. I think they're brave , and I salute them.

While we do our best to give every patient who comes to us a baby on their very first IVF cycle, sadly biological processes are not something which we can control , no matter how good our medical treatment maybe. I try to share this uncertainty with them upfront, so they can prepare themselves for what can be a rocky emotional roller coaster ride.

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 !

Fertility tests that you need—and those you don’t

This list is from the ABIM Foundation, USA.

http://www.choosingwisely.org/patient-resources/fertility-tests/

 

If you and your partner have not been able to have a baby, talk to your gynecologist or a fertility specialist. Usually both you and your partner will need some tests. Many of the tests are helpful.
But some tests are not needed.

Tests that women often need:

• Blood test to check the number and quality of eggs in the ovaries. Women who are over age 35 may especially need this test.
• An X-ray called hysterosalpingogram (HSG). This test shows if your fallopian tubes are damaged or blocked.
• An ultrasound. This test uses sound waves to check the uterus and ovaries for problems that could prevent pregnancy.

A test that men often need:
Men usually need to give a semen sample so doctors can check the number and quality of the sperm.

Just 4 simple tests !

Tests that usually aren’t needed.
Most couples don’t need these tests:

• Laparoscopy
• Post-coital test

Laparoscopy
This is a surgical procedure. The doctor puts a thin, lighted telescope through a small cut in a woman’s belly. The doctor examines the pelvic area through the telescope, looking for problems that can cause infertility. Doctors can correct many of these problems, such as blocked fallopian tubes, scar tissue, and endometriosis.
Laparoscopy has risks.

• You need general anesthesia.
• There may be complications such as infection, scar tissue, and bruising.
• Less often, an organ or blood vessel is damaged, and further surgery is needed.

You might need laparoscopy if: Your history and other tests suggest that you have a problem, such as:

• An abnormal HSG, ultrasound, or pelvic exam.
• You’ve had pelvic pain, appendicitis, or previous surgery in the pelvis. Or you have a history of pelvic infections, such as gonorrhea or chlamydia.

Post-coital test (PCT)
For this test, a woman goes to the doctor right after having intercourse. The doctor takes mucus from her cervix and checks for moving sperm.
PCT has risks.

• It usually does not provide helpful information and it leads to further testing. Studies show that the results found with PCT do not help women get pregnant.
• For some couples, having sex on a schedule adds to their stress.

You might need PCT if: The male partner refuses to provide semen for testing due to religious or personal beliefs.

This report is for you to use when talking with your health-care provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
© 2015 Consumer Reports. Developed in cooperation with the American Society for Reproductive Medicine for Choosing Wisely, a project of the ABIM Foundation. To learn more about the sources used in this report and terms and conditions of use, please visit ConsumerHealthChoices.org/about-us/.

Why do patients settle for second best IVF doctors ?

I often see patients who've been to poor quality IVF clinics. Now I can understand that they may go to a bad clinic for their first cycle because they don't know any better, but by the time they've done a second and third cycle they should be able to start realizing that the quality of care they're getting is very poor. When there's no transparency; no documentation; no counselling; and  they don't get any photos of their embryos, these are clear fed flags that the quality of care is poor. However, they continue going to the same clinic even though they are not happy with the doctor.

I can't understand this ! Why can't they switch doctors and look for a better clinic, now that they are better judges  of IVF treatment, since they have been through an IVF treatment cycle ?

Part of the reason is that a lot of IVF patients are scared and confused. What they crave is certainty. Because there's so much information on the internet and so much of it is wrong, they don't  know  whom to trust . This is why they usually take the path of least resistance - find a doctor and then repose all their trust in him.

They are also reluctant to ask questions or challenge their doctor. They've been told all their life that they're just patients , and are not as smart as doctors are. The standard advice is that a little knowledge can be dangerous , they should let the doctor make all the decisions, because he is an expert in the field. This has been the traditional practice in India, where the doctor has always played a paternalistic role. This is why patients are reluctant to get a second opinion. They end up settling for second best because they're paralyzed, and don't want to take the time and trouble to find another doctor.

They justify their inertia by saying, " At least my old doctor knows my case. How do I know that the new doctor will be any better?" This is flawed reasoning. Once you've experienced one doctor , you automatically become a much better informed patient, and can be much more thoughtful about choosing a better doctor.

There is also the problem of cognitive dissonance. Since patients have invested time and energy in selecting their first IVF doctor, they are not willing to acknowledge that they may have made a bad choice. It's much easier to continue fooling themselves, rather than take the time and effort to find someone else. This just means they are compounding their error. It's best to think of the failed IVF cycle as a sunk cost, and use the lessons you have learned to find a better doctor !

Part of the problem is that IVF doctors take advantage of this indecisiveness of patients, and therefore will pressurize patients into making a decision quickly, which is not always in their best interest. They don't give them time to think or to consider alternative options.

This is why patients continue clutching at straws.  Hope springs eternal , and they don't dare to question their doctor . They are quite happy to suspend disbelief, and say, "Even if he doesn't give me photos of my embryos, he must be a good doctor because my sister-in-law got pregnant with him."  This is wishful thinking, and can end up hurting the patient, who cannot afford to take such a laid back and casual attitude.

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 three customers every startup founder needs to delight

Every startup has three customers,  but this is something which lots of startup founders don't seem to realize.

The most important customer is of course the person who's going to pay you for using your product or service. This should be your primary focus . If you can delight him, 90% of your battle is won. However, that's not enough.

It's equally important for you to treat your investors as customers as well, because you need to keep them happy as well .  You will raise more money in the future, and this is true even if your company is doing very well , because you need more funds in order to scale up and to grow.  Your existing investors will be happy to give you more money if you treat them well, and they will help you to attract new investors too. You do need to lavish time , energy and love on your investors ! It's a small ecosystem, and getting an investor-friendly reputation will help your company to grow.

Finally, the heart of your company are your employees, and you are only as good as your team  You need to be able to sell your company to prospective employees , and convince  A-graders that you are the right choice for them. This can actually be a very hard sell, because it's hard to convince the right people to take such a big risk , given the fact that you are cash-strapped and there is no job security in a startup.

As an investor, this is a very valuable metric for me to track, because they will do far more due diligence than I ever will, because they have so much more at stake ! Can the founder attract experienced people to come and join his company ? Are they willing to give up a cushy job with a fat salary to work for him ? Can he sell his dream to them ? This shows that he's capable of creating a company with the right culture, and I much happier to back him.

If you do need to select the between the three, then put your employees first. This might seem counter-intuitive, but it's your team which creates the product which delights your paying customers - and if you have paying customers, your investors will lever have any reason to complain. This is why the mantra secret to running a successful startup is to Put Employees First. Everything else will fall into place automatically !

Why the diagnosis of unexplained infertility can be so frustrating.

Many infertile patients can't understand what their doctors mean when they tell them that their diagnosis is unexplained infertility.  How can unexplained possibly be a diagnosis ? Does this mean that the doctor is clueless and they need to find a better doctor ?

Unexplained does not that mean there is no cause for the infertility - it  just means that our technology is not able to find the reason. Part of the problem is that patients still have very unrealistic expectations of doctors and medical technology. They naively believe that we have the answers to all their questions, while the reality is that we don't.

Unexplained just means that we can't find an explanation for their infertility , and this is because the technology, tools and tests we use do have their own limitations.

However, that's really no reason for a patient to get frustrated.     Their biggest fear is that if we can't find a reason for their infertility , how will we be able to help them to have a baby?

I remind them that they should be grateful that their test results are normal - this means that everything's working fine - their fallopian tubes are open, they ovulate regularly, and the sperm count is normal. It would be so much worse to have blocked tubes  for example, because then you wouldn't have a chance of getting pregnant at all without some kind of medical intervention.

They turn around and say, "But at least if you knew what the problem was , you could then solve it." I remind them that is flawed reasoning. " How does knowing the problem make you any happier ?  Part of the reason you are thinking this way is because you are focusing on problems, while you should actually be focusing on solutions. Just because we can't identify a problem, doesn't mean that we can't identify a solution. We can always bypass hurdles without knowing exactly what those hurdles are."

The good thing about unexplained infertility is that IVF technology can help us to bypass any and all in vivo hurdles, even if they remain unidentified and unexplained. The success rates for IVF for patients with unexplained infertility are actually very good, provided the patient is young , and hasn't wasted too much time praying for a miracle.

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 life insurers need to invest in patient education

I was very excited when I saw the full page advertisement Aviva Life Insurance ran on 18 Dec 2016 in the Times of India , on providing heart care to couples.

The IRDA now allows life insurers to also cover medical illnesses , and I think this is a very healthy trend. In the past, health insurance products were primarily provided by health insurance companies. Most of these had a very shortsighted approach because of legacy issues. They were illness insurance product, which reimbursed for the medical care needed in case the customer fell ill. This is why they did not invest in preventive health care.

There was no business case for them to do so, because their customers were often not loyal for a sufficiently long duration of time for this investment to pay off.     If they invested in patient education, it was not possible for them to prove that this provided a financial return on investment. They understood that if they educated customers, they could help them to reduce their risk of certain chronic illnesses such as heart disease , by helping them to modify their behaviour and improve their lifestyle . However, if you spent all this money on the customer, and they then decided after three years to go to some other health insurer, you would effectively lose all that money you had invested in educating him !  The problem with patient education programs which are designed for reducing life style risk factors is that there are very long-term investments , and it's hard to document an ROI until you can track them for at least 10 to 20 years.

This is where life insurers have an edge ! Because customers are locked into a life insurance program, the interests of both the life insurer and the patient are completely aligned. After all, life insurers don't want their customers to become patients, and this is why they will do their best to proactively engage in patient education , so that they can help them to reduce their lifestyle risk factors.

When this happens, health insurance will actually become healthcare  insurance because it encourages customers to remain healthy, and will no longer remain just illness or sickness care insurance. This is a very encouraging trend, and I think we will see a lot more patient education activities in this space, because life insurers realize that the only way of reduce these risks is by changing customer's behavior by educating them. The health portfolio of insurers is growing rapidly in India, which is still a very underserved and underpenetrated market, which means the opportunities are huge !

I am very hopeful that Information Therapy will become a key part of their offering. Information Therapy is extremely important in mature markets such as the US, which has a much more evolved insurance industry.  Health insurers here are profitable , and they understand the need for making long-term investments in behaviour modification .

In India, the problem is that most health insurers are still not profitable, as a result of which they don't have deep enough pockets to be able to invest in these long-term initiatives, which will pay off only after a period of 5 to 10 years.

Life insurers, on the other hand, have a completely different worldview. Not only do they have very deep pockets, they also understand that if they want to grow their business and compete with the existing health insurers, they will need to provide additional offerings which add value to the customers' life.
This is a step in the right direction, and I think we will see more life insurers follow the trailblazing path which Aviva has taken. And since health insurers will also need to respond to this new challenge, customers will benefit !

How Indian medical colleges can improve medical care through Wikipedia

Perhaps the most widely accessed source of information about health topics around the world is Wikipedia.

However, the quality of Wikipedia articles on health and illness often leave a lot to be desired.

Even worse, since the vast majority are in English, they are still not very useful for most Indians. The regional Indian language editions of Wikipedia remain neglected poor cousins.

It's high time we changed this sad state of affairs. This is where Indian medical colleges can step in. Each college should adopt a particular specialty , and get their students and residents to contribute, edit and translate healthcare articles in their local language on Wikipedia. This will ensure that the content is richer ; is locally accurate and relevant ; and the references are more up to date.

Their work can be supervised by their professors, and they can be given academic credit for this. Not only will this help them to learn more, it will also help them to communicate better with their patients in the future. Retired senior doctors can also edit the entries, to ensure that quality standards are maintained.

This would be a simple and cheap way of being able to ensure that Indians have free access to reliable content on medical problems in their local language ! It would make sure that Information Therapy is available to all Indians at the tip of their fingertips.

Information Therapy can heal a sick healthcare system. It helps patients get better medical care by

    Promoting SelfCare , and helping them to do as much for themselves as they can
    Helping them with Evidence-Based Guidelines , so that they can ask for the right medical treatment that they need - no more and no less
    Helping them with Veto Power, so they can say No to medical care they don't need, thus preventing overtesting and unnecessary surgery .

In a pilot initiative at the University of California, San Francisco, 43 students did this to such effect that hits on the articles to which they were assigned jumped from 1.1 million to nearly 22 million.'

The one thing India has is a lot of medical students ! Why aren't we making better use of their expertise and knowledge ? Maybe the PMO needs to start a Wiki Health Abhiyaan !

How does Malpani Clinic compare with corporate IVF clinic chains ?

Lots of companies have set up chains of IVF clinics in India , such as Nova IVI , Morpheus, Bourne Hall and Cloud 9. Patients often ask us how we compare with them , since we are a standalone clinic. Now, every model has certain advantages and disadvantages, and patients need to weigh the pros and cons before deciding what's right for them.

The big advantage of a corporate chain is that they're spread all over the country , which means patients don't need to travel that much to reach them. They can get treatment locally , which is obviously far more convenient.

However, corporate chains have disadvantages as well, because they are ultimately run as for-profit enterprises. Their bottom line is to increase their revenue. This is why they often end up over treating patients , because their priority often is no longer providing the best possible medical care for patients , but on increasing their cash flow - after all, the purpose of a for-profit company is to make profits. These companies have multiple stakeholders, and even though ideally the patient should be the primary beneficiary of a corporate healthcare service, often this is true only as a company slogan. The stakeholders to whom priority is given are usually the shareholders who have invested their money in the corporate chain , and want the best on return on their investment. This is why sometimes patient interests come second . The focus is on increasing through put and maximizing the number of IVF cycles done in order to ensure profitability. This is why they use an assembly line approach, and the quality of the care can be uneven and patchy, depending upon who the doctor is. Also, there is a major lack of continuity of care, because patients at these clinics rarely see the same doctor twice - who they get to see depends on whose on duty on that day.

By contract, we are a boutique IVF clinic which concentrates on providing customized, personalized care to challenging IVF patients - typically those who have taken treatment in other IVF clinics and have failed. It's  our own clinic , we don't have to worry about artificially increasing the number of cycles we do by doing unnecessary IVF treatments because we are financially well off. Our primary source of income is no longer the professional fees we earn from the medical care we provide to our patients - it comes from our stock market investments . This means we have the luxury of being able to provide just the right amount of care which patients need , and don't need to upsell them into doing IVF treatment. We don't have the financial  compulsions which corporate IVF clinic chains are burdened with.

Today, we practise medicine because of the personal joy and professional satisfaction it brings us - which is immense ! Each type of clinic has a role to play in the IVF ecosystem, and patients need to decide which is right for them.

All clinics need to play to their strengths , and we take pride in dealing with complex patients who have been given up by other IVF clinics . We can focus our energy and time on these challenging patients, and bring all our experience to bear on them to maximise their chances of having a baby. Corporate clinics are forced to take an assembly line approach, because they have to follow protocols, and the quality of their doctors is very uneven, because most of them don't stick around for  too long as corporate employees.

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 !






   

Advertising by IVF clinics

Nova IVI is a corporate chain of IVF clinics all over India which recently took out a full page ad in The Times of India , advertising their IVF services. Lots of IVF doctors in private practise find this very unfair .  As individual doctors , even though we provide a commercial service and compete with these chains, we're not allowed to advertise because of Medical Council of India restrictions. Corporate chains can advertise as much as they like, which means this becomes an unlevel playing field, and the odds are stacked in their favour .  They are worried that they will lose their patients to these chains, and feel threatened.

My take is very different.

I feel that these ads create a lot of awareness amongst infertile patients. Instead of wasting their time and money on ineffective infertility treatment options provided by gynecologists who are not infertility specialists , these patients understand that IVF offers them their best chance of having a baby. This is why they are much more likely to seek out IVF clinics.

When they look for one, perhaps they will go to Nova IVI first , because they ran the ad.  However , most patients these days are smart. They will also look for alternatives , and get a second opinion. This means there is a trickle down effect , and all IVF clinics will benefit in the bargain, because a rising tide helps all ships.

Also, when they do their first IVF and it fails, they're going to look for a better clinic for their second attempt, because they have become more sophisticated.  Instead of taking away our patients, these ads result in our patient base growing even more , because we are a boutique IVF clinic which specialises in providing personalised, customised high tech care with high touch !

Also, patients understand that when clinics take out such expensive ads , someone needs to pay for them - and this is a cost which is ultimately borne by the patient. It's an indirect cost and it's hidden, but marketing is expensive and, finally it's the patient who foots the bill for all ads. Sophisticated patients understand this , and will always look for better options.

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 !

Patient feedback in the Complaints and Compliments book at Malpani Infertility Clinic

Our patients keep us on our toes, and we take great pleasure in delighting them.

Here is feedback from our patients from the Complaints and  Compliments book we have in our clinic. We request patients to fill in their comments after their embryo transfer.

Complaints and compliments about Malpani Infertility Clinic

We value patient feedback, because it helps us to do a better job at delighting them.

This is what some of our patients have to say about us - in their own handwriting, after their embryo transfer

IVF patients beware - lots of expensive "add-on" treatments are unproven and waste your money

"Nearly all costly add-on treatments offered by fertility clinics to increase the chance of a birth through IVF are not supported by high-quality evidence," BBC News reports, covering the findings of a review by experts in evidence-based medicine.

IVF "add-ons" include a wide variety of treatments such as pre-implantation genetic screening, where the chromosomes of conceived embryos are checked for genetic conditions, as well as various drug treatments for blood clotting and immunity.  

Lots of IVF clinics "up-sell" their patients additional treatments, such as PGS, immune therapy, and NK cell testing . These help to add to the profits of the clinic, but do not improve success rates.

Sadly, patients are very vulnerable, and doctors exploit their ignorance !

Please, please read this excellent article, so you don't waste your money on unproven costly options.
This describes what happens in the UK - conditions are much worse in India !

Why I do my angel investing through my family office.

I've been an angel investor for quite a few years, and I've made lots of mistakes along the way. In the beginning I would invest through networks and syndicates and this had lots of advantages because it accelerated my learning process. I could piggyback on the wisdom of others who had been doing it for many more years.

This had its own set of issues however. For example , the process can be fairly bureaucratic because it takes time to get everyone on the same page, and this can be frustrating. Because there are so many people involved, there would often be differences of opinions - for example, when it was time to raise the next round, some of us would be supportive, while others would not. This would cause a lot of grief - not only for the founder, but for the angels as well. This is why I decided that I should try investing on my own.
Now, since this can be a fairly large chunk of money, I do this through my family office. The whole point of being an angel investor is not just to sign a cheque - you hope to add value to the founder's life. This is why having a family office helps . It allows us to set up a systematic framework and a process which we can follow.

This is not just for doing due diligence before signing the cheque - it's  also for handholding the founder afterwards , in case he needs any help with tweaking his business model or raising another round of funding. He knows we are there to assist him.

The advantage of a family office is that many heads are better than one, which allows us to be much more thoughtful. This is important because the decision as to whether to invest or not often depends on how you judge the character and integrity of the founder. Because this is intangible, it can be very hard to do . This is why we plan multiple rounds of interaction with the founder . This offers us different perspectives , and we agree to find him only when everyone agrees that he is a good guy .

As an angel I feel my job is to help catalyze the founder's success, which means we are in a service industry. We try to play to our strengths. Our weakness is we're not a VC fund - we don't have the deep pockets which they do . On the other hand , because it's my personal money , we are a lean and mean machine. We are much more agile, and can be flexible. I'm not answerable to some institution, and can take idiosyncratic bets.

This means that sometimes I am likely to be impulsive. Having a family office provides structure and balance which helps me to ensure that we follow a process . I can listen to both my heart and my head. I don't get carried away just because I have fallen in love with the founder.  Finding the right balance is extremely important for an angel .

Being able to do it through a family office, which has financial experts to guide me, is invaluable. It allows me to increase my bandwidth, so we can screen many more deals. It also gives the founder confidence that we are there to support him after we have funded him - after all,  running a startup is a marathon, not a sprint. Since we now have quite an extensive portfolio, we are well connected in the ecosystem, and can use our network to open doors for the founders, allowing us to marry the agility of  an angel with the systematic processes of a VC fund. We try to be open and transparent about our process, because we value the founder's time, and our reputation !

Why we need 100% reservation in medical education

Medical education in India is broken. A major problem is that medical college seats are no longer allotted to students based on their merit. The majority of seats are reserved for students who come from " backward classes "; and another huge chunk are reserved for rich students whose parents can afford to pay a lot of money to buy a seat in private medical colleges by paying the hefty capitation fee.

This problem has now become a growing cancer which is progressively eating away the quality of graduating doctors . The best solution is to reserve all the seats in all medical colleges based only on merit.

This step would solve all the problems once and for all . Thus, students from different social backgrounds and religious minorities will stop clamoring for reservations for the group they happen to belong to , because admissions will become a level playing field, and the only way to get in would be to prove your competence by working hard . Politicians will no longer start medical colleges simply in order to make money.

All kinds of reservations - whether they are based on the fact that someone is rich and can afford to pay; or that someone comes from a backward class, have a pernicious domino . Once you allow one bad doctor to graduate , he often ends up becoming a medical college professor , because often he is not competent enough to be able to practice independently. He will then start creating sub-standard medical students , as a result of which the cancer spreads throughout the system. This is why we no longer have any confidence in the competence of the doctors our medical colleges are turning out.

The short-sighted focus  - either on making money ; or in keeping the backward classes happy in order to earn their votes ; is going to harm all of us in the long run , because we'll end up being treated by poorly educated doctors , who will damage our health.

Does your IVF clinic follow best practices?

Most IVF patients are pretty clueless when selecting an IVF clinic. They naively believe that all clinics are pretty much the same. This can lead to disaster when they go to a poorly equipped clinic - one that doesn't have enough experience or expertise or take short cuts - for example, by depending upon " travelling embryologists " to do IVF for their patients, because they don't have in-house full time expert embryologists.

That's why you should understand what IVF best practices are and check whether your clinic follows these best practices , before actually paying the money for your IVF treatment. Once you start your IVF cycle, this is a sunk cost , and you can't back out.

What are the best practices you should look for ? These can be checked at the time of the first consultation. Good IVF clinics will create a treatment plan which is customized to your needs and share this with you; they will document what your medical problems are and explain to you what alternative solutions are available. They will also let you know what the costs and timelines are.

During your cycle, they will  share information with you , and let you know what's going well, and what's not. They will show you your  ultrasound scans ; and give you photographs of your embryos before the transfer , so that you have complete documentation , and you know proper processes has been followed properly. This will improve your chances of having a successful IVF cycle.

Treating the fragile egg syndrome

How to do ICSI when the eggs are very fragile

This is a guest post from  Dr Saiprasad, our Chief Embryologist.

When we do ICSI we introduce a single sperm into the egg in order to fertilise it. Puncturing the cell membrane of the egg  cleanly with the sharp hollow ICSI pipette is a key part of the ICSI technique, and requires a skilled embryologist to do this properly. If it's done clumsily, the egg will die.

Most normal eggs have an elastic cell membrane. We need to penetrate this with the sharp ICSI needle in order to introduce the sperm into the cytoplasm of the egg. If we do not break the membrane, the sperm will remain outside the egg , and will not be able to fertilise the egg, resulting in ICSI failure.

On the other hand,  if we apply too much pressure, and suck up too much of the egg's cytoplasm into the ICSI pipette, the egg will die. This is why the resilience of the egg's cell membrane is so important.

What do we mean when we say “The Eggs are Fragile”? When the Eggs have a Soft cell Membrane, they die when we do ICSI. When we introduce the ICSI needle to inject the sperm into the Egg, the egg cannot with stand the sharpness of the needle , and hence it dies after ICSI. The problem is that these eggs look completely normal, and it's only when we actually do the ICSI do we realise that the eggs are fragile.
Another major issue is that the death of the egg may not be instant, and we only realise it had dies when we examine it a few minutes after doing the ICSI, by which time the damage is already done.

Another issue is that because the results of ICSI  are so dependent on the skill of the embryologist,  in most cases the death of an egg after ICSI because of a clumsy embryologist, and not because the eggs were fargile.

Recently we treated a patient who had a history of having Fragile Eggs. She had undergone 3 ICSI cycles in Sweden earlier . In all her cycles, the eggs  had degenerated (died) after performing ICSI, and she had never had good quality embryos to transfer

We have encountered excessive fragility of eggs  in the following groups:
1)    SMALL SIZED FOLLICLES : When the Eggs are retrieved from small sized follicles (Size < 10 mm), they usually turn out to be fragile , even if they are mature Eggs.
2)    AGE : We usually see that patients above 40 years, with low AMH, produce few eggs which are often Fragile.

What can we do to handle such fragile Eggs , in order to reduce their degeneration rate and achieve a better fertilization rate ?

1)    CONVENTIONAL  IVF
When we suspect the Eggs to be fragile, the best option is to do Conventional IVF, which doesn’t involve manipulation of gametes using needles.  With IVF, the risk of degeneration because of the mechanical insult of the ICSI pipette is zero..
However, we cannot do Conventional IVF for all patients, as good Sperm Quality is
a  Prerequisite for doing IVF. If the Sperm count and motility are poor, we are forced to do ICSI, otherwise we will end up with total fertilisation failure.

2)    INCUBATION TIME
It is possible to reduce the Fragility of Eggs by incubating them in vitro before doing ICSI.. Even if the eggs are mature, their cytoplasm may be immature after the egg retrieval.  This is why it is advisable to incubate the Eggs after Egg collection for at least an hour, to avoid damage to the eggs due to cytoplasmic immaturity.
A prolonged long incubation of Eggs usually helps in the case of fragile Eggs. We incubate the eggs for 3-4 hours post egg collection if we suspect the eggs to be fragile .


3)    ASPIRATION OF CYTOPLASM
In ICSI, when we inject the sperm into the Egg, little bit of the egg's cytoplasm is aspirated into the pipette to break the cell membrane ( oolema ). This is needed to activate the Egg, which is very Critical for fertilization.

In the case of fragile eggs, we need to modify our technique.
While injecting the Sperm into the Egg, when we pierce the ICSI needle into the Egg, we usually see an indentation due to the elasticity of the cell membrane and the cytoplasm . We then aspirate a little bit of cytoplasm to break the oolema. However, if if the Egg is fragile, we usually do not see any indentation as the membrane of the cytoplasm is very soft. In fact, this is the first clue we get that the egg may be very fragile !
















Normal Egg during ICSI (Indentation in Cytoplasm)                 

Fragile Egg during ICSI (NO Indentation in Cytoplasm)      

If we do not see any indentation when the ICSI pipette is advanced into the egg, it is advisable not to aspirate the cytoplasm, because this can damage the  fragile egg.
However, this is a tricky call, because if we do not aspirate Cytoplasm, we may end up having no fertilization as the cell membrane may not break, and the sperm maybe deposited outside the membrane.


4)    INJECTING A SINGLE EGG AT A TIME
We need to treat Each Egg as an individual  Patient , rather than doing ICSI for all the eggs at one time.
Injecting 1 egg at a time is the best option when we are suspecting Eggs to be Fragile.
This can help to minimize damage to the Eggs, because the embryologist is much more aware, and can modify his technique for each individual egg.

The Embryologist can inject 1 Egg; put it back into the incubator, wait for some time, and then observe after a few minutes if the egg has degenerated or not. This is because it can take time for a dead egg to look dead ( the cytoplasm turns dark), and if the embryologist injects all the eggs in a single batch, he may not even realise he has killed a lot of the eggs until it is too late.

After evaluating the fate of the first Egg, the Embryologist can then decide about whether or not to aspirate the cytoplasm for the other eggs. This way he can modify and adapt his technique, depending upon how the eggs behave.

This needs patience, and self-awareness on the part of the embryologist, but this can make a world of a difference to the patient !

Patients with poor ovarian reserve: is there any point in flogging a dead horse?

Women with poor ovarian reserve who have regular cycles are extremely difficult to treat. Because they have regular cycles , they expect that they will have good quality eggs.  This belief is reinforced when they do IVF and their eggs fertilise and the doctor gets embryos.  They feel that these should implant, because this was their only problem. Since their uterus is normal , and since IVF has helped them to make embryos from their eggs, they think success is assured.

However, when their embryos fail to implant, they go to pieces. With repeated IVF failures, they start getting even more desperate , and are advised to explore options such as surrogacy.  This is bad advice.

The problem is that their major bottleneck remains their poor egg quality. Just because an egg forms an embryo doesn't meant that that embryo is good enough to become a baby . This is something patients with poor ovarian reserve need to understand .

However, because they are so desperate to transmit their own genes to their child, they often pursue treatment which is futile , and ends up wasting a lot of time as well as money. Sometimes it's better to cut your losses and accept that you need to move on to plan B, which is using donor eggs. Yes, this is a hard decision, but it's the one which gives them the highest chance of becoming a mother.


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 !

I will be speaking at HITCON 2017 in Ahmedabad

This is the third year I will be talking at HITCON in Ahmedabad.

I really enjoy these sessions, because the audience is enthusiastic and keen to learn. I think this is because the conference organisers charge doctors a fee to attend the sessions, which is why they take the conference seriously.

I especially like the fact that there are no pharmaceutical sponsors   for the conference. This is self-funded, and has been growing from strength to strength, year on year.

Plenary session at Hitcon: Dr.Aniruddha Malpani,a leading IVF Specialist from Mumbai,.

Avid medical articles writer,tech savvy and entrepreneur in HIT.

He will be taking on *How to make techno naive doctors-Tech Savvy*.

A must attend for all doctors who are interested in Healthcare Technology and start using newer things. Be there. Register Today. Hitcon- 2nd edition of Healthcare care technology conference for doctors by doctors.

This and much more. 21st January,Saturday in Ahmedabad

Pre conference,1pm to 5pm,Registration fees Rs. 250 & 22nd January Sunday,main conference 9am to 4pm,

Registration fees Rs.500.You can register online and pay by credit cards or cheque.Queries or Questions ?Want us to collect cheque ?  Hitcon helpline 8460656213.Book your seats log on to http://managementmedicos.com/hitcon-2017/

The movie Dangal will improve the sex ratio more than the PCPNDT Act

The falling sex ratio in India has been a matter of concern, which is why the government of India passed the PCPNDT Act , with the hope that this would help to increase the number of girls . The intention was that the Act would stop people from resorting to sex selective abortions.

Sadly, the act has had previous little impact . It has become a very punitive act , which focuses on punishing doctors who are allegedly performing sex selective abortions. 9 times out of 10, the doctors who've been hauled to court for flouting the Act is not because they have been caught performing sex selective abortions , but because they have committed clerical errors in filling in the infamous Form F. The Act is obsessed with regulating the misuse of ultrasound scanning, and just ends up criminalizing doctors whose records are not picture perfect, even though they may not be performing any sex selection. This is one of those draconian laws where the doctor is considered to be guilty, until he can prove that he is innocent !

This has become a huge tragedy, which has caused a lot of harm , because patients are being deprived of ultrasound scanning facilities . Also, because of the obsession with ultrasound scanning, the Government is failing to control the use of blood tests which are being misused to commit female feticide.

We are barking up the wrong tree , because we are more focused on measuring population-based numbers such as sex ratios, while we should be encouraging each individual couple not to discriminate between having a son or a daughter.

This is where movies like Dangal shine. For one thing , it's a story which is told very well . It strikes an emotional chord, and speaks to your heart . Most importantly , it talks to each individual viewer, and shows them that girls are as good as boys - that there's no advantage to prefer having a boy as compared to a girl.
Once this message gets across , and people internalize it and understand it, this is going to have a far more lasting impact as compared to any amount of laws we can pass , or sting operations we carry out. Even slogans like Beti Bachao, Desh Badhao are just empty platitudes.

A well told film can have a powerful impact, especially given the fact that it's in a setting like Punjab, which has always had a fascination for boys. Aamir Khan is a great actor, and has a lot charisma. The trailers suggest that it's a compelling story , which is full of action, which means people will enjoy watching it !
Aamir's show called Satymev Jayate was disappointing because his team didn't do its research properly, and oversimplified matters. I think he has learned from his mistakes, and will hopefully stick to his core focus - acting - which is where he shines !

This movie is the kind of positive intervention which will reduce gender discrimination in India. We may not be able to judge the impact until a few more years go by, because it takes time for people to change their behavior , and their attitudes, but I am very hopeful !

My guess would be that the sex ratio at birth in India would definitely improve over the next four years, and while the PCPNDT activists may want to take credit for this, my guess is that it will movies like this which would have a far greater impact, and the tragedy is we'll never be able to give them the credit they deserve.

How the media can stop unnecessary doctor bashing

Today, wherever something goes wrong in a  private hospital, the doctor is blamed. He is called negligent , and is often beaten up. There's a lot of unnecessary violence, and doctors get a lot of bad press.  This is why the image of the medical profession suffers.

The aggrieved family approaches a reporter with an emotionally charged story. This if often biased, incomplete and factually wrong. The reporter is happy to carry it, because any story which features negligent doctors gets a lot of attention, and they want to be the first to "break" the story - " if it bleeds, it leads. Sadly,  medical accuracy becomes the  first casualty of this slip shod approach.  A good reporter will try to contact the concerned doctor to get his side of the story. However, doctors are scared of the press, and are usually advised by their lawyer to clam up, as a result of which they are very reluctant to talk to journalists. This is why the reporting is so one-sided and incorrect.

Here's a solution if editors want to make sure that their stories are factually correct.

Each medical college should set up a Press Advisory Board which consists of senior medical teachers. Journalists should be able to reach out to these medical college professors 24/7, who are trusted and respected sources of medical expertise. They would provide them with the medical background they need to be able to make sense of the facts , rather than be swayed by an emotionally upset patient.  This would help to provide a more sympathetic and balanced understanding of  medical complications - the vast majority of which are not due to errors or negligence ! Armed with the right context, doctors would then no longer be painted as villains, and the medical profession would be able to do a better job taking care of patients.

How medical colleges can improve healthcare in India

There is no doubt that the municipal corporation teaching hospitals such as KEM, Nair and Sion are brilliant medical institutions. I've been trained at them , and the clinical training is excellent because there are so many patients who throng to these hospitals for their treatment. They do an outstanding job, especially when you consider the constraints which they have to operate under. Thus even though their bed capacity may be 2000, they will often have a far larger number of inpatients ( many of whom are nursed on a mattress on the floor ) because they don't turn any patients away.

While they are doing a great job, there's plenty of scope for them to do even more.

The biggest strength of a teaching hospital is its human capital - their medical staff . At present , this is being underutilised, because they are only being used within the hospital .They have so many renowned leading medical teachers and professors , who should be producing Indian language patient education materials, which should be shared online. This will allow them to reach out to people in their homes, through their mobile. By providing them with accurate, reliable, local language information, we can help patients to get better medical care. Sadly, the opportunities for reaching beyond the four walls of the hospital are being overlooked.

It's not just the medical professors - it's the medical students and residents as well. These junior doctors are hard working, but all they seem to be forced to do is cram for their exams, so that they can pass these. Why can't they be used to create clever apps to help doctors to reach out to patients in their homes. If we can go to there the patient is, we don't inconvenience patients ; and we don't overload hospital facilities by forcing patients to come to hospitals. We can use telehealth to amplify the expertise and experience of the hospital's medical staff. This is good for the students as well, because it will increase their clinical exposure , and they will be able to learn a lot more "real life" medicine, rather than stuff their heads with the exotic illness and rare diseases which hospitals attract. It will also help them to become more empathetic, because they are reaching out to patients, rather than limit themselves to the comfort zone of the hospital.

These apps can be used for triage; combined with the ability to talk to a doctor live, as needed. This will be much more convenient for the patient , who will then not have to wait for hours , waiting to be see in the hospital OPD. This will be much more cost effective as well, because the corporation won't have to spend so much on each patient. The truth is that lots of the problems which cause patients to seek medical attention are simple problems , which can be solved in the comfort of the patient's home, without the patient actually having to come to the hospital.

This is a great opportunity, and the numbers which you're talking about are mind boggling. Technology can be used to connect hundreds of medical students, residents and doctors with the millions of citizens who live in Mumbai.

The problem is that we still are stuck with an archaic top heavy model , where everything seems to revolve around the hospital , and the tertiary care facilities it provides. We need to flip this model around, and think about what we can do to make sure that patients don't need to come to the hospital in the first place.

These hospital should partner with the IITs and IIMs to create medical entrepreneurs, where the next generation of doctors can cope up with clever out of the box solutions , adapted to Indian needs.
Health insurance companies should be happy to fund these efforts, as they can use these to improve their outreach activities.

4G is now easily available, and most people have mobile phones. Why can't we make use of these new options so that we can provide care in a new format which is much more patient friendly ?

Improving healthcare by using the human capital in our medical colleges

Indian doctors have a great reputation globally for being excellent clinicians, and the government teaching hospitals do a great job at providing cost-effective medical care to poor patients . They take pride in the fact that they don't turn any patient away, no matter how poor he is. They make excellent use of their resources, and  treat patients at a tenth of the cost which a private hospital levies.

However, one of the things which they are not making the best use of is their human capital. These teaching hospitals have medical colleges, which means they have teaching staff; medical professors; lecturers ; as well as medical students. We are not utilising their skills optimally, and this is a shame.

Why aren't these medical professors creating MOOCS ( massive online learning courses ) to teach doctors all over the country? They are all experts in their own field, but why are they restricting their teaching only to the medical students within the four wall of their campus? Why can't they reach out to all medical doctors all over the country? Not only would this be great for medical students from other medical colleges, it will be very helpful for practicing doctors as well, because then they would have access to authentic information which is relevant to Indian conditions. This would be provided by a local authority , and in a local language, which means it would have a much greater impact.

These hospitals should be using digital technology to amplify their outreach activity. This will allow them to improve their efficiency and effectiveness , so they can do far more than what they've been able to do in the past.

The students areall digital natives - and there are so many opportunities waiting to be explored ! We need to make better use of the young blood in our medical colleges, and allow them to use their brains to think out of the box.

These hospitals could become world leaders  in creating models on how cost-effective medical care could be provided frugally to the poor. At present, the medical skills , experience and expertise of their doctors is not being utilized adequately.

We can learn to use telehealth, and just like the IITs and IIMs have become world leaders by applying entrepreneurship to the IT field, why shouldn't these teaching hospitals also aspire to become thought leaders in health care?

Sadly, rather than stimulating them with exciting challenges, all we end up doing is getting them to cram tons of stuff , and then exporting our brightest and best doctors to the West. Why not create opportunities for them within India itself which will allow them to improve the health of millions of Indians ?  The social impact and personal fulfillment would be so much more ! We already have the people, the skills and the tools - we just need to marry them together.

We're not utilizing our next generation of doctors well at all. This is because no one is really answerable or accountable. The seniors have become so used to doing things in the old-fashioned way , that they are not able to innovate . We need to think out of the box , so that we can create models which are tailored to what the Indian patient needs, rather than blindly imitating what the West does.

Why is the Government turning a blind eye to the misuse of new technology for female feticide ?

Ultrasound scanning can be life saving . However, because it was being misused for gender determination and female feticide, the Government introduced the PCPNDT Act and started  monitoring ultrasound scanning more closely, to prevent this abuse.

However , technology moves on, and it is now possible to determine fetal gender at 9 weeks of pregnancy with a simple blood test on the mother, using NIPT technology ( non-invasive prenatal testing) .

According to a new research report by RNCOS entitled, “Indian NIPT Market Outlook 2022”, the Indian NIPT market represents a market with remarkable potential for growth.

The UK Govt has already expressed concern that this test is being misused for sex-selective abortions.

However, the Govt of India is not doing anything to prevent the misuse of this technology to prevent female feticide. Blood testing is much easier than ultrasound scanning, and if these blood tests are not carefully monitored, female fetuses will continue being aborted, because the Govt of India is focusing purely on checking ultrasound scanning. The sex ratio will keep on dropping  because government officials are not being proactive.

We cannot afford to miss the forest by getting bogged down in the trees !

'POINTLESS' IVF TREATMENTS THAT CAN WASTE THOUSANDS

'POINTLESS' TREATMENTS THAT CAN COST THOUSANDS

Endometrial scratch (up to £350)

Scratching the womb is said to release hormones that make it more adhesive, but studies found it does not help women with fewer than two failed implants.

Assisted hatching (£615)

May help repeatedly unsuccessful couples by softening the embryo’s outer shell so it can ‘hatch’ more easily, but no evidence this works for older women.

Time-lapse monitoring (£775)

Camera shows up abnormalities by taking pictures as embryos develop, but no good quality evidence for routine use.

Embryo glue (£320)

Chemical with added hyaluronic acid developed to help the embryo ‘stick’ to the womb lining. May increase birth rates, but can also cause unplanned multiple births.

Intra-cytoplasmic sperm injection (up to £1,390)

Sperm injected directly into egg is said to help fertilisation, but experts argue this is not necessary if a man’s sperm is normal.

Intra-cytoplasmic morphological selected sperm injection (up to £600)

Uses a microscope almost 6,000 times more powerful than usual to identify any defects, but creates no more pregnancies than a basic sperm injection.

Immune therapy (£1,500)

Based on claim a woman may fail to become pregnant because her immune system rejects the embryo. A review found blood level of ‘natural killer’ cells, which fight infection, has no effect on implantation.

Pre-implantation genetic screening (£3,100)

Identifies abnormalities, screening out embryos unlikely to implant. May cut miscarriages, but has not been found to raise birth rates in women with a good prognosis.

Read more: http://www.dailymail.co.uk/news/article-3972968/The-great-IVF-swindle-Couples-desperate-baby-sold-treatments-not-need-8-000.html#ixzz4RPm8N1kM