Why IVF doctors continue to order useless tests and offer wasteful treatment

Patients who fail an IVF cycle are extremely vulnerable . This failure is often the last straw, because they are not sure what to do next. They have no idea why the cycle failed, even though the doctor was so optimistic at the time of the transfer. They are usually completely in the dark as to what was done, because most IVF clinics are remarkably opaque . They do not share information with their patients, and the standard explanation is - It is our clinic policy to keep all  IVF medical records for our files. Many feel quite hopeless , and this is why many go to another IVF clinic for a second opinion.

The new IVF doctor will often take advantage of their ignorance, depression and unhappiness . He will highlight all the tests which the earlier doctor didn't do , and say that the cycle failed because the earlier doctor was sloppy, and did not do the workup properly.  He will then proceed to rectify the problem, by ordering lots of expensive and sophisticated tests. Some of these are so " exotic " that they are only done in a single laboratory in the world, and they will ask the patient to get this test done only in that lab. The fact that no other lab in the world offers that test should actually be a red flag - this means that the test is unproven and untested , and its clinical value is still controversial.

However, patients are naive and come to exactly the opposite conclusion, because they are naive.  They interpret this behaviour as suggesting that the new doctor has access to highly specialised technology which the earlier doctor was completely ignorant about  - and this explains why the new doctor must be better !  The new doctor is also happy to point out that one of the reasons the earlier cycle may have failed is because the first doctor didn't order this advanced test. However, now that the patient is in his safe hands, he'll be able to  find out what the problem is , and fix it, thus increasing her chances of getting pregnant.

This sounds extremely logical, and patients are quite happy to do what the doctor says, without realizing that all these tests proven and haven't been validated.  The number of tests is mind-boggling, and seems to increase year on year. This includes: sperm DNA fragmentation tests; immune tests, such as NK cells testing;  endometrial TB PCR testing ; and ERA ( endometrial receptivity assay) testing.

So why does so much scientific quackery flourish in IVF? I think there are multiple reasons - both at the personal level, as well as the level of the medical profession.

As regards the individual doctor, he is liable to be waylaid by the same biases and prejudices every human being is susceptible to.  These have been well documents by Kahnemann, and doctors are not immune to this just because they are medical professionals. The much bigger tragedy is that they are completely unaware of their personal prejudices, because they are not taught basis critical thinking skills. They have never been taught to question, because success is medical college is a function of their ability to regurgitate the facts which they are forced to cram into their heads.

Doctors remember only their successes, and conveniently forget their failures. The individual clinician does not have a long term follow up of his patients, and cannot carry out controlled clinical trials in his practice. Let's look at a cohort of hundred patients for whom he advises these tests , and then "treats" the abnormality in all of them. Let's also assume that the tests are completely useless . Now, twenty of these patients will conceive - not because of the tests, but inspite of them ! However, because they will bring the doctor a box of chocolates, he will always remember them - after all, our brains are wired to remember memorable stories. The doctor will share this anecdote with everyone, and these successes will reinforce his belief that the tests are useful.

What about the other 80 patients for whom he did exactly the same tests and offered the same treatment, who didn't get pregnant. He would rather forget about them - or they will desert him, and find another clinic, which is why it's so easy and convenient to lose track of them . This explains why individual doctors have such strong biases about what they do, even though their protocols have never been validated properly.

Am I being excessively harsh and critical ? Perhaps - but this is only because I expect doctors to hold themselves to a higher standard of scientific integrity. The truth is that it's very easy to confuse cause and effect, and many events - including the success of an IVF cycle - are random.  Thus, if the patient gets pregnant after the "immune treatment", the doctor is happy to jump to the conclusion that it was his treatment which resulted in the pregnancy, because this is the way the human brain is wired .

While individual doctors maybe biased, why isn't the medical profession  as a whole able to fix the problem ? Shouldn't IVF doctors be able to get together and analyse the evidence objectively , so that they can collectively determine what "best practises" are for their patients. Can't these be offered uniformly across the board to all patients?  Why is there so much practise variation ? Why can't IVF doctors agree with one another ?  This is the holy grail, and this is what evidence-based medicine is supposed to offer. However, real life is far more complex, because of all the politics involved in the medical profession.

Thus, when experts disagree, they selectively quote the studies which reinforce their point of view, and trash all the rest. It's easy to bad-mouth a study you don't agree with by disparaging its quality. Either it was done too many years ago; or the statistical analysis was faulty; or the numbers were too small to draw a reliable conclusion ; or the results are suspect because they seem to be manipulated.

The truth is that like all of us, doctors also first make up their mind based on their emotions and personal experience; and then they selectively interpret facts in order to buttress their preconceived notions.  The danger is that because they are so sure they are right, they don't even realise that they are selectively massaging the data quoted in the medical literature to make it conform to their pet beliefs ! The truth is that the Devil can selectively quote the Bible to suit his needs - and doctors are also happy to do so!

Thus, if you point out that a research study shows that NK cell testing is useless, they will find a hundred reasons to criticise the study and point out its flaws.  This could include: the patients were not selected properly; the test was not performed properly; or the results were not analysed correctly.

They highlight the fact that the way they do the test in their own clinic is far superior to what the paper described, and given this shortcoming on the part of the researcher, they are justified in ignoring the results of the paper, which is completely opposite to what their personal experience shows. After all, when "eminence-based" medicine is at offs with "evidence-based" medicine, very few doctors will have the intellectual humility to accept that they might be wrong !

It's very hard for a doctor change his beliefs, especially as he gets older. When you are an "expert" who is invited to give lectures at conferences, you are supposed to have all the answers - and you start behaving as if you actually do.

Indian IVF doctors  are especially good at this. If they come across a high quality paper which casts doubts on their beliefs, they will trot out many reasons why the paper is flawed and why they are right. These include:
- Indian patients are different, and these findings don't apply to India
- My patients are different,  so these findings don't apply to my patients
- I am different , so these results don't apply to my practise ( because I am better than everyone else)

We are all subject to basic human foibles, and a major hurdle which stops us from correcting our prejudices is cognitive dissonance - how can you accept that you were doing something wrong all these years ?

In the past, these doctors would quote their "extensive personal experience" to justify everything they did. The most popular phrase was - " in my experience". Now that everyone knows how unreliable this can be, they have become much smarter. In that past, they would refuse to publish their research , because they did not want to be challenged. Now they have become even sneakier. They publish their papers in poor quality medical journals which call themselves "peer-reviewed" , but are happy to accept any paper for publication if the author is willing to pay the "publication fee" which they charge. The doctor will often "manufacture" the data ( usually by adding a zero to inflate the numbers of patients they treat, and doubling their success rates) , and then cite their "published research" as proof that their views are valid ! Sadly, predatory medical publishing has become widely prevalent  in India, and it's possible to get any rubbish published today. To add insult to injury, they don't even have to pay  for the publishing, because their friendly pharmaceutical medical representative will pay on their behalf, as part of their " continuing medical education " services to the medical profession! These journals are not even worth the paper they are printed on - but have become extremely popular in the Indian medical community today, because it's so easy to get anything published, and give it the veneer of   respectability !

Fed up of your doctor ordering too many tests ? 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 do so many Indian gynecologists believe that all infertile women have TB ?

I recently attended an  IVF conference in Delhi, and came away with the impression that a lot of IVF doctors there seem to feel that every Indian patient who's infertile has tuberculosis. They feel that it's a ubiquitous disease, and that the only reason we don't diagnose it for everyone is because we don't look for it hard enough.

Their " impression" is based on their personal experience with their own patients, and they don't care what the foreign medical literature shows. After all , TB is extremely common in India, and very rare elsewhere, so why would foreigners know anything about genital TB? This means that Indian doctors are the experts on this disease, so they can get away with any claim they choose to make. They see TB everywhere and anywhere, and I don't think any of their patients has not been subjected to anti-TB treatment.

They seem to be desperate to find TB in all their patients - and this sometimes seems to become an obsession with some of them. They will run an entire battery of tests in order to make this diagnosis, to prove that their "clinical impression" is correct.

Yes, there are patients in India who are infertile because of genital TB, but TB is becoming uncommon in India.  Ironically, the problem is not the TB anymore - it's the misdiagnosis and overdiagnosis  by poorly informed IVF doctors which causes infertile women much more harm !

There are standard established methods for making the diagnosis of TB, but when these doctors run a single test and get a negative result, they do another one. If that's still negative, they do a third; and if that's negative as well, they do a fourth, until they finally get one test result which is finally abnormal. They then triumphantly point to that result and tell the patient, "See, we found the TB , and now we need to start your treatment."  In some cases, even if all the results are normal, they will still start the treatment "empirically" based on their clinical judgment and experience !

It's only when they finally " treat " these patients with antiTB drugs are they satisfied, because they refuse to believe that infertile patients could not have TB. It's hard for me to understand why they have this single-minded obsession with unearthing TB ! Here's a typical example. They start by doing an endometrial biopsy, and sending  it for culture, which is the gold standard for making the diagnosis. If this is negative, they say - Yes, we all know that there are lots of false negative, so let's do more advanced tests, because it's not very sensitive, and can miss the diagnosis.

They then send it for PCR testing , which is a grossly unreliable test, because the slides are often contaminated with environmental mycobacteria, and the PCT tests cannot differentiate between the bacilli which cause genital tuberculosis , and the environmental bacilli , which are ubiquitous. If that also comes negative, they do another fancy test called gamma interferon; or a blood test called TB gold; or a Mantoux test. If all these are negative, they resort to doing a PAMP test ( a esoteric, expensive and exotic test, which is available in only one clinic in the entire world - which  should tell you all you need to know about its reliability !)

Many doctors don't even bother to do the tests in this organised sequence. They just send the endometrial tissue sample for all the tests at one time during the routine workup, using the crude principle of brute force ! Now, if out of these 10 tests, nine are negative, and one is positive, they'll point out to that abnormal result triumphantly and say, "See, we finally found that elusive tubercle bacillus, which was lurking in your body. Everyone else missed it, but now that we have identified it, we need to treat you, so you can finally get pregnant."

What I can't understand is out of 10 tests , if nine are negative, doesn't that mean that the patient doesn't have that disease? However, they are in no mood to apply common sense. They will not rest until they get a positive result, and they won't let their poor patients rest either !

This overtesting and  overtreatment causes a lot of harm. Needless to say, it doesn't improve their fertility, because they never had TB in the first place. Yes, some patients will get pregnant after taking the TB medications, but they would most likely have got pregnant even if they hadn't taken them ! What's worse is that these drugs can damage the liver, and kidneys, because they are toxic and need to be taken for many months.  Also, because patients waste valuable time taking these anti- TB drugs, they end up reducing their chances of getting pregnant.

The problem is that once the doctor's mind has been made up, he is wedded to his beliefs. He refuses to believe any evidence which could challenge his ideas. The problem becomes worse as they get older, because their attitudes harden along with their arteries as they age. They are very selective about what they are willing to listen to, and if anyone disagrees with they, they will disregard their opinion as being rubbish. After all, aren't they the world authority on this topic ? How dare anyone challenge them? Any paper which dares to differ is a load of rubbish - either because the doctor who published it didn't know what he was doing; or because the tests they used weren't sophisticated enough.

This is the reason they do all their tests only in one single laboratory, because ( according to them) no other laboratory is equipped to provide the accuracy and precision which they require ! This makes absolutely no sense to me. It's all eminence-based medicine, based on an individual doctor's opinion.

 As they grow older, they acquire positions of power. The become the opinion leaders in the community, and lots of other doctors blindly follow whatever they say, simply because they don't know any better. This is how these flawed beliefs have come to dominate the worldview of IVF specialists today .

What I find especially fascinating is that no respected TB specialist agrees with the results of their  tests - and yet they merrily continue "treating" lots of hapless women with antiTB drugs !
If this problem was restricted to only a few IVF clinics, it wouldn't be so bad. However, because these doctors are leading professors who give talks at medical conferences, many practising gynecologists get brainwashed into believing them. Sadly, most doctors are not taught how to think critically. They are intellectually lazy, and happy to believe what the experts say. When a message is mindlessly repeated  many times, it starts becoming perceived as gospel truth, even though it is false. This is why we are now seeing an epidemic of overdiagnosis and overtreatment of genital TB .

My fear is that this will have a long-term public health impact, because the indiscriminate use of antiTB medicines will lead to the emergence of MDR - multi-drug resistant TB.  I do hope the public health department starts insisting that all patients who are put on anti-TB medicines because they have been diagnosed as having genital TB are reported to the government, so we can curb this menace before it gets out of hand.

Has your doctor told you  that you have TB ? 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 IVF patients feel helpless

One of the most worrisome aspects of an IVF cycle is the uncertainty involved. The patient never knows whether the next cycle is going to work or not - and neither does the doctor ! The problem is compounded by the fact that they know very little about what happens during IVF treatment. This is because most doctors don't bother to explain anything to them . Either they don't have any time , or they use so much jargon that the "explanation" is clear as mud for the poor patient, who is too scared to ask for clarification .

While patients do go on the Internet to do their homework for themselves, they still find it hard to get clear answers to their specific queries, because doctors don't like being questioned. Sometimes going on the Internet leaves them even more confused, because they don't know which sites are reliable. Different sites sometimes provide diametrically opposite information , and they don't know whom to trust. This is why so many patients feel powerless and helpless when starting an IVF cycle, and many just give up and pretty much let the doctor decide what to do.

When some of the hardier ones get fed up of trying to make sense of the doctor's cryptic comments, they once again turn to trying to find answers on the Internet. Their husbands and relatives admonish them for doing this. Their well-meaning advice is based on their perception that they are needlessly adding to their stress levels by spending hours online . They remind them that half knowledge is dangerous ; and they should just leave everything up to the doctor, who is the expert, rather than try to figure out stuff on their own.

I think this is a big mistake. It's been proven that assertive patients who ask smart questions get far better treatment. They are much more in control of what's happening, and can make decisions in partnership with their doctor. Also, good doctors respect these patients far more; and their participation acts as a safety net which prevents errors from happening.

Patients should self-prescribe Information Therapy from reliable websites , so that they have realistic expectations, and do not have to depend completely on their doctor to find out what's happening. Otherwise, they will get blindsided when the cycle fails, especially when the doctor has been over-optimistic.

It's a great idea to think of the IVF cycle as a game you can play, where you try to anticipate what's going to happen next. How many follicles will you have ? What will  their size be ? What will your blood test estradiol level  likely to be ? This will help to reduce your anxiety , because you know what to expect. And even if things don't turn out the way you want, at least you'll realize that something seems to be amiss , and you can start taking corrective action by bringing this to the attention of your doctor .

 At the end of the day, you need to remember that doctors can't read patients' minds. IVF treatment is elective, and  your personal preference plays a big role in deciding which option you should select. This is why you need to speak up. If you take an active interest in what's happening, you'll be able to make your own decisions in partnership with your doctor. 

This way , you'll have peace of mind that the process you followed was correct, no matter what the final outcome is. Patients are mature enough to understand that while doctors can't control outcomes, we can make sure that our clinic is following global best practices , so that we can maximize your chances of having a baby .  Just like you can't afford to leave everything up to God, you can't afford to leave everything up to your doctor either. The good news is that today you have the tools to be more actively involved in your treatment.


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 !

But I need only one embryo to get pregnant !

Patients with poor ovarian reserve can be extremely hard to counsel, especially when they're young and have regular periods because they can't understand why they're not being able to get pregnant and why they're failing repeated IVF cycles. After all, they have eggs, they're growing embryos, lots of other women are getting pregnant, even women who are much older than them. Why aren't they being able to manage?

I think it's important they understand that just because they're making embryos doesn't mean that these embryos are good quality enough to be able to implant. This is a problem especially, for example, when they do a day 2 or a day 3 transfer and they have a good 8-cell embryo and they think, "Great. Since my uterus is normal and the doctor has managed to make the embryo for me, I should get pregnant." Unfortunately, if you have poor quality eggs, you end up with poor quality embryos which don't implant.

Of course, the big problem is you can't make out looking at an embryo whether it's good quality or not. This is true whether it's a day 3 transfer or a day 5 transfer. After all, we know that even perfect embryos will have genetic abnormalities which will prevent them from implanting. We don't have the ability to test these because PGD only allows us to check for chromosomal abnormalities and not genetic abnormalities. Older eggs, because they're older or because they come from ovaries which have aged, as reflected by poor ovarian reserve, will often accumulate a lot of these genetic abnormalities as a result of which these embryos are destined never to implant.

There's no way we can prove this, so that makes it even more frustrating for the patient. We get a good quality embryo, of course the patient is excited and so is the doctor because these are challenging patients, hard to work with. Being able to make an embryo for them is very gratifying, but we forget that patients don't just want good quality embryos. They need a baby.

One solution, of course, is to grow these embryos to day 5 and not transfer on day 2 or 3. Now, it's very tempting to put them back on day 3, especially when there are such few eggs because each of these embryos is worth its weight in gold, but my point is that if it's going to arrest, then it's better that it does that at the lab, so at least we have useful information we can assimilate and utilize when making treatment plans for the next cycle in case this cycle fails. What happens if the embryo does arrest? So be it. If it's going to arrest in the lab, it would have arrested in the uterus as well and would never have become a baby. If it is going to become a baby in the uterus, then it will definitely form a blastocyst in the lab as well. Of course, you need a very good lab and a very confident doctor, but this is the best approach.

Just because you make a good quality blastocyst, and even if you do PGS and that PGS is normal, that doesn't mean that embryo is going to become a baby, as I've already explained. You need to accept the fact that some of these things are beyond our control. You need to be prepared for failure so that you don't go to pieces and you're able to move on and think of alternative options rather than get paralyzed.

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 depressed and unhappy infertile patient

Most infertile patients are unhappy and stressed out. They're depressed , because they're unable to perform the basic biological function every woman is designed for - to have a baby . For some of them, their whole life seems to revolve around this inability to have a child.

Having kids is a basic biological urge which is hard wired into us. It's something which we all take for granted.  No one ever anticipates they'll ever have a problem with their own fertility , and when they do find out that they're having difficulty conceiving , this comes as a rude shock.

Usually one hopes that it's going to be a simple problem - something which will get fixed by having more sex; going for a holiday ; or maybe visiting a gynecologist and taking some tablets. But when none of this works and they find out they have a problem which requires more aggressive treatment, such as IVF, they start getting depressed. They feel very sorry for themselves because they feel that their bodies have let them down.

Even the poor starving beggars on the road have babies effortlessly. They start resenting their friends who get pregnant at the drop of a hat. They get heartburn when they hear about young unmarried girls terminating unwanted pregnancies because they had sex irresponsibly. They believe the world is unfair , and they're getting a raw deal.

It can become hard for them to deal with these feelings , because it's tough to talk about them . You can't keep on complaining to your husband every time you get a period, so you start bottling your unhappiness . It's very hard to know whom you can share your personal angst safely with.
Most people can be surprisingly un-empathetic . While they may not mean to be unkind , they usually offer completely unhelpful suggestions, such as - Just relax and go for a holiday and you'll get pregnant. Or , why don't you just adopt a baby, that's so much easier.

This is not what someone who wants to have their own baby wants to hear, and this is why you start cutting themselves off from the rest of the world. This just makes matters worse, because you then get isolated and lonely. When you don't know whom to turn to for help , the stress and the depression starts becoming a negative, vicious cycle.

It starts affecting your self esteem and eroding your sexual desire, thus exacerbating your marital disharmony. Your husband may say that he loves you and doesn't care about having a baby, but this just makes it worse, because you think he is being insensitive and heartless as he does not understand your personal heartbreak. You are also upset that he is so clueless about the impact infertility has on the social standing of the woman in Indian society. He seems to be sandwiched between trying to keep his mother happy and placating you, and ends up doing neither well. You feel betrayed, because he is not protecting you from social taunts and barbs. Family quarrels flare up because of your inability to have a baby, and you try to run away from these problems by burying yourself in  your work.

However, when your heart is hurting , there really is no place to hide .  Some women will look for counselors, while others will turn to spiritual guidance for solace. Most are completely lost , and they start getting worried that they're going crazy . Having a baby becomes a single minded all-consuming obsession , and they don't know how to handle this.

Infertility doctors also contribute to the problem, because most are not very empathetic. They think of the woman as being a patient who has a medical problem which they need to fix.  For example, if she has blocked tubes, they are happy to do IVF for her , and they treat this as a cut and dried medical procedure, without understanding her emotional angst.

Most IVF clinics are like assembly lines , where everyone is treated like a widget. There's very little attention paid to the emotional needs of the patient , who's often left to fend for herself . If she is lucky, she can find a friendly nurse she can confide in.  Sometimes , enterprising women form informal support groups in these clinics. Patients who are doing a cycle together, start connecting with each other during their interminable waits. so they can support each other in their time of need.

Infertility can be a depressing and lonely journey , and it's sometimes hard to get support either from family members or from a husband . It's easy to feel lost , and you can consider taking antidepressants  to help you cope better. However, it's far better to understand that what you are suffering from is quite normal. This is called a reactive depression, and if you learn to be kind to yourself, you will find the inner emotional resilience to bounce back.

Please remember the Serenity Prayer
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.


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

Repeated IVF failure - what next ?

It can be extremely hard for me to counsel faithful patients who have experienced repeated IVF failure in my clinic . Every time I do an IVF cycle for them , I do it with a lot of hope. If it fails, I tweak the protocol, and hope that we will get lucky this time. However, even though everything goes perfectly, the cycle fails again - and again.  When she comes back with a negative beta HCG, it's hard for me to tell her to do next.

Her question is simple enough , "What do I do next ?"  This is hard to answer, because we don't have enough scientific information on which to guide her . Should we change the eggs? the sperms? or the uterus? Or should she change her doctor ? On what logical basis do we make these changes?

It's very easy for me to give advice to my patients, but I need to be thoughtful, and think about the basis on which I am giving them my advice? Is there any scientific  reason for it? Is it just a shot in the dark?

More importantly, I need to provide the patient with actionable alternatives. Often, the truthful answer is that we don't know why the cycle failed, so it's hard to know what to change and why. Nevertheless , she is looking to me for guidance and direction, and this puts me in a quandary.
This responsibility puts a lot of burden on me, especially because I know that I have personal biases. I want to do my best to make sure that these don't colour the advice I give to my patients .

After all, it's my patients who have to live with the consequences of the decision I help them to make. This is why I'd rather they made it for themselves , rather than based on something which I told them. I do my best to share my ignorance and uncertainty with them . This often backfires. I can feel them thinking in the back of their mind - "If the doctor doesn't know what the next step is, then what am I supposed to do? I'm just a poor patient." They feel completely lost.

However, it's very important for patients to provide their personal inputs because they're the ones who are going to become parents. They have to decide, "Am I comfortable with the concept of surrogacy ? Or is adoption a better option for me ? Does using donor embryos make more sense?"

If I have a patient who has failed multiple IVF cycles in my clinic, even though everything seemed to be perfect, then it's my personal belief that  embryo adoption is a better option than surrogacy . I feel the evidence clearly shows that the seed is more important than the soil . This is why 60 year old women can get pregnancy with donor egg IVF - because their uterus does not age !

However, this is my personal opinion - I cannot back it up with scientific proof for the individual patient. It's not something which other doctors may agree with, and it may not be something which the patient is comfortable with.

I can provide a rationale for my advice, but it's obviously based on probabilities which apply to groups of patients - not to the individual patient sitting in front of me. This is why I am aware that the  advice I give has limitations - and I try to emphasise these to my patients .

I need to be able to justify the advice I give to my patients ? It's not enough for me to say, "Look, I'm the doctor - just do what I tell you to."

It's very helpful for patients to get an alternative perspective. This could be a second opinion from another doctor, and I encourage them to do this. They have peace of mind that they have covered all their bases and explored all possible medical options. I also tell them to talk to their spiritual guru if they have one. He has a completely different way of looking at life , and his view maybe much better than my medically reductionist  perspective of making these decisions.

A lot of patients ask, "Is there anything else we can do to pinpoint what the problem is?" The reality is often we can't , and doing pointless test doesn't help. I agree that repeating cycle after cycle is not a very comforting thought. However, something this is what IVF boils down to - a series of hits and misses until you  hit the jackpot.

I tell patients that they need to make a list of all their possible next steps. It's useful to brainstorm; and using a mind map , as well as free flow writing can help you thinking through what your options are, and their pros and cons as they affect your personally.

It's very helpful to take a treatment holiday , so you can clear your mind and start with a clean slate.

No matter what you decide, you still need to prepare yourself for possible failure  - after all, there's no guarantee that even surrogacy or embryo adoption will work.

At some point, you need to ask yourself, "Have I done enough?" If your heart tells you No, then you need to plan your next steps.  You need to be realistic, and accept the fact that you are entering the realm of the unknown . I agree this is scary, but then this is true for so many things in life.  When science doesn't have all the answers, it's perfectly logical to go by what your heart tells you - follow your gut feel !

After all, when you started your first job, did you know how well you'd perform ? Sometimes we make decisions we regret later on, but that's what life is all about. It is always going to be plagued with uncertainties, but we need to keep on doing our best as we muddle along.

It's very helpful to step outside yourself and pretend that it's your close friend who has the problem, and that she is asking you for help. Counsel this friend , and then try to follow the advice you give her .
These can be taxing times, not just for the patient, but for me as well . It breaks my heart when patients who have reposed their trust in me don't get pregnant inspite of our best efforts.
Do remember to step back and take a long - term, perspective. If you survive this trial by fire, not only will your marriage become much stronger, you will be a much better person. You will also make a far better parent , no matter what particular decision you choose to make.

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 embryologist - the unsung hero of the IVF clinic.

Lots of patients don't know how to evaluate how good or bad an IVF clinic is. This is hardly surprising , because when they go to an IVF clinic, all they do is see the doctor,  who is a clinician.

However , the real heart of IVF treatment lies in the IVF laboratory, where the embryologist takes tender loving care of your eggs and sperms , so that he can make beautiful embryos which the doctor can then transfer back into your uterus.

Sadly, most patients never get to see an embryology lab; and they never get to talk to the embryologist. They have no idea about how good or bad the lab is. Is it well equipped ? How good are the quality control standards it follows ? Does the lab have a full-time embryologist or not ?
It's a bitter truth that most patients still don't know that most IVF clinics in India do not even have full-time embryologists. The gynecologist basically sets up a lab , and then hires traveling embryologists who come and do procedures on an episodic basis.

Yes, they will get pregnancies , but the success rate will be low, especially for difficult patients . The poor embryologist is forced to do all the cases in 1-2 days. This means he cannot focus on quality control ; and since he leaves , he cannot stay on to freeze the supernumerary embryos, even if they are of high quality. This is the dirty secret behind why most IVF labs in India don't freeze their patients spare embryos, this reducing their chances of having a baby. The embryos are either discarded, or donated to other patients without the patient's consent !

This is why so many IVF clinics today are forced to cut corners. It's not because the doctor is bad, but because they do not have a good full - time embryologist to run their IVF lab.

Quite frankly, if I had to choose between a good clinic and a bad lab , versus a bad clinic and a good lab, I would rather choose a bad clinic with a good lab , because a good lab can compensate for a bad doctor. This is because what the gynecologist does in an IVF treatment cycle is usually very cut and dried. He simply follows a published treatment protocol , which is why there's not much to pick and choose between the medical treatment plan of most IVF clinics.

However, what the embryologist does in the lab makes a world of a difference, and a bad embryologist can butcher embryos by ill-treating them. Sadly, the poor unsuspecting patient has no clue as to why her embryos are always of poor quality . The doctor either blames her eggs or her husband's sperm, while the real problem is a poor quality lab!

Of course, your best bet is to find a good clinic with a good lab , as this will maximize your chances of getting pregnant . However, what happens most of the time is that patients unfortunately end up in bad clinics , who also usually bad labs, because they don't do enough IVF cycles. This is why they don't have enough experience because of an inadequate workload; and they don't have enough expertise, because they can't afford to employ a full-time embryologist. It's very hard to get skilled embryologists in India , because the training still leaves a lot to be desired. This is why most of them learn by trial and error , and aren't good at their job. This is why there is such a world of a difference between the success rates of good clinics and bad clinics.

Unfortunately, there's still a major lack of transparency as regards IVF treatment today. Most clinics don't even both to give a treatment summary to their patient, leave alone photos of their embryos ( which should be compulsory, because it documents that the lab managed to create high quality blastocysts).

The ICMR wants to start protecting patients by bringing in regulation , and it suggests standards which all IVF clinics need to follow . However, implementing this in real life is still going to take a long time. That's why the rule is caveat emptor - let the patient beware ! You need to do your own homework , and the best way of doing this is by making sure that the lab provides you with photos of your blastocysts routinely every time you do an embryo  transfer. This is the gold standard , and as easy way to check how good your IVF clinic really is !

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 IVF doctors lie to patients !

A patient who had failed an IVF cycle at another clinic asked me for a second opinion by email.

I requested her to send me photos of her embryos. When she asked her  clinic for these, her IVF doctor said - We don't take photos because we do not expose embryos to a flash. !


The doctor was taking undue advantage of the poor patient's ignorance by lying brazenly.

No flash is needed to take embryo photos - the microscope stage illumination is enough ! 

All good clinics take embryo photos routinely to document the quality of their treatment.

Her next question was -  What could be the possible reasons of poor embryos where me and my husband both are of 30 years. ?


The answer is obvious. A poor quality lab is the reason 90% of the time

Her doctor told her that it was because of poor egg quality.

Another great example of passing the buck and blaming the victim !

Labelling emotions helps infertile couples to cope better with them

Have you ever felt emotional, but couldn’t pinpoint why? Labeling your emotions is an important first step in dealing with them. Research has shown that people who write about emotionally charged episodes experience a marked increase in their physical and mental well-being. When you’re going through a tough time or a big transition, try this exercise: Set a timer for 20 minutes. Write down (on paper or on your computer) your emotional experiences from the past week, month, or year. Don’t worry about making it perfect or readable; allow your mind to let go. Use phrases such as “I have learned,” “it struck me that,” “the reason that,” “I now realize,” and “I understand.” These phrases help you contextualize your emotions and gain perspective on why you’re feeling a certain way. You don’t have to save the document; the point is that the thoughts are now out of you and on the page.

https://hbr.org/2016/11/3-ways-to-better-understand-your-emotions?

Straight from the heart of an infertile woman

I admire and respect my patients, because I learn so much from them

I just got this post from G.

She has a lot of courage to bare her soul like this, and discuss topics which are considered to be taboo. This is powerful stuff, because it's straight from the heart .

She writes well - it's raw and brutally honest.

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Hello doctor ,

I felt better post writing down last time and speaking to K - Thanks for your advice.

Never had an ache/cloggy feeling at the back of my head / neck post that .. which I use to associate(may be wrongly ) with this specific stress...

While i have been genuinely happy and positive last 2/3 weeks ( feeling ultra light post I wrote the earlier blog )  .. Here's an another episode which psyched me this week end .

I decided to share it for 2 reasons :
1) feel good myself again ( so what if it's at the cost of making you read through a long post and may be it's utter nonsense)
2) 2 solutions which I think I can offer

Since my husband and his family is away for a wedding out of town ... I have the house to myself for few days.

I decide to not go .. feeling blessed my in laws exempted me as my Singapore business trip in round the corner and they thought it would be rather hectic for me to do both the trips back to back.

I am happy to be exempted also because the wedding is going to be at  P and if i attend it , I will be in direct scanner of prying village ladies ( who have done nothing good other wise but have birthed children at early ages in their life ). They 'obviously' mean well when they specially come across suggesting help  .. but I have a feeling they covertly settle scores against the new age women whom they obviously hate inwardly for being  independent and not as cultured as they perceive themselves to be.

 Also here's a second and bigger reason to be happy ...  there is an another person in my life who helps me be happy . It's a man in my office whom I have known for 8/10 months now but we laugh and click like anything in last few weeks only. He flirts casually and has given me enough reason to dress well and feel good about myself during an otherwise boring schedule at work.

I am not inclined towards infidelity at this stage (I think infidelity is unethical due to my upbringing in utopian values) but have had thoughts of "what if a person like him was my life partner". This change from routine is welcome as it makes me happy ... and I will do anything  these days to make myself happy!

 The man is a father of 2 .. happily married to his college love for 15 odd years and is 10 odd years older than me ... Still we click ... He flirts .. I encourage... and we famously hang out together during our office breaks .

I feel guilty but feel much better with him and I feel it's totally worth it.

I have attracted eyeballs of lot of other office guys ( for whom i never existed in their list of good looking women to be ogled at) and some how it's making me feel better( my  true self few days back would have cringed and felt sick at attracting such unwarranted attention from the opposite sex )

It's tricky to explain.. but  I think this is therapeutic. I am a lot more confident about my looks. I am eating right and thinking right as I want to look better. I come back home smiling ..as I speak of this friend all the while to my husband and carry a smile all day long. I feel am glowing which no one  has missed at office and I receive a lot of compliments from unexpected people.

My husband is a little insecure and has bought me a valentine gift (an expensive perfume) after 6 years of never remembering it or justifying no need of buying it and finally, we had great sex multiple times last week. Timed still but GREAT after long time none the less.

So all in all, I am in happy space thanks to this new friend. So here's the first tricky solution from me:  if you think it helps other women in similar situation like mine, please ask them to bond with such someone special or find a temporary romance to rejuvenate their own marriage which may aid their process of baby making.

The episode that psyched me :
I am surprised, in spite of my conscious effort to not let anyone intrude in my attempt to be postive and happy , how my own mother could destroy it all with close to zero intention or effort.

It all started with her visiting an ayurvedic doc along with her sister for her own health issues and him asking her "are you tensed about something ?"

Now, she could be tensed about many things but her top of the mind recall is my condition.
So she doesn't mention it to the doctor (who asked for it) but has to and most definitely tell me 3 times in a day last 2 days in all earnest.

How do I deal with it? I don't react first few times with just a "hmm" as my response.

After hearing it the 6th time, when I sense my own mother is waiting for a discussion on the topic 7th time around I give her a piece of mind.

She justifies it saying "me and my sisters are concerned about you and we mean well".
I tell her in a rude tone " you showing concern and discussing endlessly hasn't helped my condition in 5 years and most definitely not help in future as well."
On these specific days I get a feeling my in laws are better than my own parents!

I also discuss it with my brother and sister in law and this ruckus disposes  me from my happy state and I am miserable for a day.

My second solution is to : conduct professional sessions for parents, in laws and immediate family members of infertile women to tell them of the women's physical and mental state during infertility and post taking hormones. Hormonal medicines  do tend to make the strongest of women weak emotionally. The anger about everything in life I believe is due to that  ( I realised this post talking to K) I hope I can write a book "Inconceivable : the Indian way" which lists  these special situations.

The immediate solution I find to feel happy again is the man from my office.
I WhatsApp him (nothing pertaining to my terrible mood) and we discuss how the weekend went. Our conversation has favourites like organic farming /romantic songs /drawings / his wife's paintings /my rangolis/ jokes on his 40 + age /our business venture (if at all ) together / basically lots of diverse things! It all lasts 1.5 hrs and peps me enough to 1) keep me going all through next week when I am going to be away from him on business trip and 2) write it all down at midnight for you.

By the way,  this friend also knows about my infertility to a little extent and shows concern/empathy.  I hope some time in future, I can tell him how beautifully he played his role in making my baby :)

Regards ,
G

Does this resonate with you ? Would love your comments !

Have you failed many IVF cycles ?

Patients who have failed multiple IVF cycles are extremely frustrated. They are their wit's ends, because everything they have tried has failed so far. They are desperate enough to try to clutch at straws. They are willing to explore many different options, including changing  multiple IVF  clinics. They are willing to be treated as guinea pigs, and will subject themselves to painful and expensive tests, in the hope that they will  find the success which has eluded them so far.

When you are confused, it's very helpful to start from first principles. Begin from the basics, by making a list of all your possible options, so you can think through them logically.  Remember that along with medical options, you also have non-medical options, and it's always worthwhile exploring these in parallel.

For now, let's just focus on what your medical choices are. You need to remember there are only four variables in an IVF cycle, and you need to decide which variables you're comfortable with tweaking and changing.

Thus it's possible to change the eggs; the sperm; the uterus; and the doctor.

If there is a problem with the eggs, you could use donor eggs ; and if  there is a problem with the uterus, you could use surrogacy. Unfortunately , patients often get very confused because there are so many variables. The trick is to change  just one at a time - and it makes sense to change the one which is likely to give you the best results.

Thus in this day and age with ICSI, it's very unlikely that the sperm will be a problem. This means there's very little need to use donor sperm , no matter how poor the sperm count is , or how abnormal the sperms are, or what the sperm DNA fragmentation level may be. This is why it ultimately boils down to choosing between changing the eggs or changing the uterus - either donor eggs or surrogacy. This choice often confuses patients . Most feel that if the embryo did not implant, this means that their uterus has " rejected " the embryo. This is why the majority intuitively believe that there's something wrong with their own body, and that surrogacy would be their best option. Sadly, doctors  are also quite happy to perpetuate this myth, because surrogacy is so much more profitable for them. And if the surrogacy cycle also fails ( as it usually will, because the problem was never with their uterus in the first place, but with their poor quality eggs), then patients are deluded into believing that at least they tried the most advanced option medical science had to offer them . They are then forced to reconcile themselves to the bitter fact that they will never have a baby, but the biggest tragedy is that they never even realise that they were led down the wrong path by their doctor !

Similarly , if they miscarry after an IVF cycle, they feel it's their uterus which is to blame; and their doctor explains that they have high NK cells or some " embryo-toxic factor " which prevents the embryo from implanting . However, this is not true.  In pregnancy, a useful rule of thumb is that the seed is active and the soil is passive. If you do need to change something, it's far better to consider using donor eggs rather than to use surrogacy.

This has been proven  many times. This is the reason why an older woman's fertility declines - not because there's a problem with her uterus, but because her egg quality takes a beating as she ages. Even if she produces embryos and transfers these into a surrogate, the chance of that cycle failing or miscarrying remain extremely high.  Remember that there never was a problem with her uterus in the first place !  Poor quality eggs result in poor quality embryos , which in turn result in failed IVF cycles or failed pregnancies.

If you are confused, the best option is to change your doctor . Getting a fresh second opinion will help you explore all your options more intelligently, and give you peace of mind you tried your best !

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 infertile patients start obsessing over their test numbers

I'm a big believer in patient empowerment and feel that patients should do as much homework as possible, so they understand what their options are and can make well-informed decisions for themselves. Yes, this does involve a certain amount of effort, but it is possible for patients to decipher medical jargon and understand their options.

Lots of husband and family members worry when patients spend time on the internet trying to make sense of their results because they feel that half knowledge is dangerous and that these are decisions which are left to the doctor. Because infertility treatment is elective, there are so many variables involved and so many different options, I think patients need to apply their minds so they can express their personal preferences when deciding what to do next. As with everything else, you can carry this too far. Just like being completely ignorant about what's happening and leaving everything up to the doctor is not a good idea, I think looking at numbers out of context also carries its own sets of problems. This seems to be a very uniquely American problem where not only are the doctors completely obsessed with minor variance in test results, so are the patients as well.

Here's an example of a patient who sent me her report and what her concerns were.

Hello. I am 29 years old, my husband is 32. We tried to conceive naturally for around 6 months but due to luteal phase spotting, saw an RE who recommended clomid. We did 4 cycles of clomid with possible chemical pregnancy (highest b-HCG of 5.4). We have now completed fresh cycle of IVF (though we saved all embryos for frozen transfer). I had 32 mature eggs retrieved->19 fertilized->14 made it to day 5 and were frozen. Out of those we had genetic testing done on 8 and 5 are normal. I am preparing for a frozen transfer and noticed that my TSH level was 2.69 with Free T4 of 1.15 after my last cycle with clomid (that day beta hcg was also 2.6). Prior to that i have had my thyroid tested several times throughout the years and TSH has been between 1.1-1.9 with free t4 of 1.3-1.5. Should I be worried about this TSH? Could it be due to clomid? Or could the the b-hcg from trigger or chemical pregnancy have affected the value? Thank you!

Now this poor lady has been over-tested and over-treated and the problem is that he's interpreting her results all wrong. I agree that's not her fault. After all, she's not a doctor and I get that, but she also needs to be far more balanced in her approach and find a reliable doctor who will help to her to make sense of these rather than someone who causes her to worry unduly and creates a lot of anxiety in her head, especially when all these so-called abnormalities are just normal anatomical variance of no clinical importance. Otherwise she's going to drive herself crazy and most probably her husband as well, in her pursuit of the perfect numbers, whether this is a TSH level ... She's obviously been completely over-tested and over-treatment.

Again, this is a very uniquely American phenomenon which, unfortunately, Indian doctors seem to be adopting because it is far more remunerative for them to do as many procedures as possible irrespective of whether these procedures are helpful for the patient or not. The general tendency is this blind belief in technology where the rule seems to be, the more you do the better your results. Without realizing that a lot of these procedures may sound very logical but may actually turn out to be harmful and they've not been proven to improve pregnancy rates. Unless they're subjected to clinical trials, there's no reason for patients to subject themselves to being treated as guinea pigs, especially at their own expense, which is something which makes no sense to me.

As with everything else, do what Gautama Buddha said, "Follow the middle path."

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 to the right path  !

Why I love my work as an IVF specialist

In today's age , work is a very important part of the way society perceive us . Being proud of what you do also adds a lot to your self-esteem. I consider myself doubly blessed in the work which I do , because being an IVF specialist is extremely gratifying on multiple fronts.

We've been doing IVF for many years now, and I think it's one of the best jobs in the world , because we allow people to start a family - we help them to bring a new life into this world. Children born after IVF treatment are an asset to the country , because they are deeply loved. They are usually very well brought up, because their parents have moved heaven and earth in order to have a baby. When you help them to have a baby, not only have you transformed their lives, you've transformed the lives of all their family members as well , which means being an IVF specialist allows me to bring so much joy in people's life on a daily basis.

It also allows me a lot of professional autonomy . Our IVF clinic is a standalone clinic , and not part of a corporate chain. I don't need to be part of a large hospital , which means I can focus on doing what's right for my patients without having to worry about meeting financial targets or filling in paperwork and insurance forms. I can focus on doing the one thing I know how to do best - taking good care of my patients.

Because we've been doing this for many years, we've got very good at it. We have a high success rate, which means patients come to us from all over the world . This is very gratifying , because being able to help them to succeed after they have become despondent because they have failed IVF cycles in other clinics can be very exhilarating.

Our website allows me to share my knowledge with infertile couples from all over the world, and we try to help patients to make well-informed decisions. Our patients are well-read and intelligent, and they teach me a lot about how to cope with life's adversities, as they battle with their medical problems. Being infertile can be emotionally very stressful, and I learn how to remain graceful and unflappable even when life is unkind and unfair.

The beauty of IVF is that it is a superb blend of science and technology; medical therapy and surgery; advanced imaging; as well as counseling . All these facets are equally important, which helps me to become well-rounded. When I do a consult, I need to understand what the patient's going through , so I can empathize with her. We need to deploy advanced technology in our IVF lab , to be able to create high quality embryos. We have to do precise surgery , such as egg collections and embryo transfers. We need to interpret ultrasound scans to monitor the cycle; and we need to make sense of blood tests and design treatment protocols customised to the patient's specific problems. IVF is one of modern medicine's success story , and allows us to make babies for patients whom we would never have been to help even 40 years ago.

Finally, IVF allows me to work with my talented wife , Dr Anjali. She is much more caring than I am, and has far better clinical sense and intuition. This means we can combine our strengths to provide the best care to our patients.   Would you like to share this with your colleagues? Email Be the first one to share this post

We need to stop medicalising IVF treatment

IVF is an extremely effective form of therapy for infertile couples . It is the final, common pathway for any couple with an infertility problem, because it allows us to bypass whatever hurdles nature may have put in their place. For example, whether the tubes are blocked , or the sperm count is low, IVF allows to do with the lab what is not happening normally for that infertile couple in the bedroom. That's why IVF is an ART, which stands for Assisted Reproductive Technology and not Artificial Reproductive Technology.

A big problem today is that everyone seems to have medicalized IVF. They think of it as being abnormal or artificial . Thus, some patients are worried that the sperm selected for IVF may be weak , as a result of which the baby born may be abnormal. It's high time we put to rest these myths and misconceptions.

IVF has now been around for more than 40 years. Millions of babies have been born worldwide after IVF and it's been proven to be safe and effective, both for the babies who are born as well,  as their mothers. This is quite intuitive , if you stop to think about it . Effectively, all we are doing in an IVF cycle is what would normally happen in the fallopian tube in the woman's bedroom if she were having sex normally , and she were fertile . In IVF, we do exactly the same process in the petri dish in the incubator - we are just replacing the fallopian tube with a test tube ! Once we've made the embryo, it's exactly like any other woman's embryo.

There is absolutely no difference between an in vitro embryo and in vivo embryo , and this is the reason why an IVF pregnancy is exactly like any other pregnancy . We need to reassure our patients that what we are doing is safe , and that an IVF pregnancy doesn't require any special care or precautions. Thus , after the embryo transfer, they don't need bed rest or dietary restrictions.
After all, women doing IVF are not patients ! They're normal women , and we're just helping them to kickstart their pregnancy.

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 !

Worst case scenario planning for IVF patients

For most IVF doctors and patients , failure is a taboo word.

It's something which no one wants to talk about, because everyone wants to discuss only the chances of success. This is obviously far easier to do and much more pleasant, but I don't think evading hard issues really makes a lot of sense. I think it's always important to protect your downside before considering the upside.

Not only is this far more sensible, it helps you create a safety net. Being prepared for the worst improves your emotional resilience and ensures that you don't go to pieces in case your cycle fails.  Some patients think their world will end if their IVF cycles fails. However, the truth is that life continues even after IVF failure .

If you fail to prepare for failure, and put all of your eggs in one basket (pardon the pun), then if that cycle does fail, you're likely to be so emotionally devastated that you may just give up completely and refuse to do another cycle.  Ironically, repeating the IVF cycle would actually be your best option, but because you were not emotionally prepared for failure, you deprive yourself of your best chance of having a baby . You cannot afford to go to pieces just because the cycle fails.

The good thing about planning for the worst case scenario in IVF is that there is no medical risk to  IVF failure - the failure will not damage your ovarian reserve, increase your risk of cancer, or harm your physical health . The risk is predominantly financial and emotional , and because these can be anticipated , you can plan for them.

You need to know exactly how much you are going to have to spend; and how much you are willing to spend in your pursuit of a baby. If there are limitations , you need to think of creative solutions so you can work around these. For example, you can talk to your doctor , and ask for a discount, or opt for shared risk program which reduce your financial risk.

Exactly the same reasoning applies to the emotional risk of failure as well . Rather than start catastrophising if the cycle fails, or sugar coating everything by assuming that your cycle will succeed, you need to be hard headed and realistic enough to accept the fact that it may fail.

You need to put the IVF treatment in the right perspective. It's not an emergency treatment, and you can take your time until you are mentally and physically prepared to go through an IVF cycle. Even if the cycle fails , you will always have peace of mind you did your best, if you do your homework and make a well informed decision.

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 !

Aamir Khan as a social entrepreneur

Celebrities have a lot of power .  Because of the adulation which they attract , they are often used as brand ambassadors to lead social campaigns. They have the power to do a  lot of good because their actions catch the eye of the public.

Lots of people are quite cynical about some of these celebrity endorsements. They believe these "go-good" activities are used by them as vehicles to improve their public profile and popularity. Every once in a while however, you come across a celebrity who uses not just his face and his goodwill, but also his brains to be able to do something to make the world a better place.

A great example of this is the work which Aamir Khan is doing with the Paani Foundation, which is battling the water shortage in Maharashtra by systematizing watershed management.

Watershed management to tackle drought has been around for many years. What makes Aamir's initiative praise-worthy is that he is leveraging his public persona intelligently.  He realises that the impact a celebrity has can be quite transitory , which is why the Paani Foundation insists that the villager do the work themselves - they need to take ownership of the solution if the changes need to be long-lasting.

He has tied up with his friend, Satyajit, and they make a great team. I learned more about their unique model at fundraiser hosted by Motilal Oswal on 8 Feb 2017.

For one, they've decided that their foundation needs to self-destruct ! They believe that if they do a good job, then the Paani Foundation will become irrelevant in five years. Secondly, they're not disbursing any money to the villages themselves, which means they have stayed away from a potential source of corruption and allegations of favouritism.

They are creating competitions , and awarding prizes to the villages which do the best job at water harvesting and conservation - an excellent example of gamification ! They are using Marathi TV channels and the government to create awareness, and invite villages to compete for these prizes.

Their role is to educate villagers about  what needs to be done, but I love the fact that they're not doing the work - they are getting the villagers to do it themselves. This is what makes their model so magical - it can be scaled up exponentially ! They propagate watershed management knowledge - and then it's upto the villages to implement this themselves.  This way, even if the villages don't win prizes, they still end up as winners because they have more water than they had in the past.

Equally importantly, they're tying up with the Maharashtra government, because they realize that  this movement needs governmental support. The government has far more muscle, far more reach, and far more money - and the Foundation is amplifying this very cleverly by using Aamir Khan's clout to attract villagers to take part in these competitions.

Since the villagers themselves need to do all the work, they are the ones who need to take the initiative to fix their own problems - the Foundation only acts as a catalyst.  It is this sense of ownership which makes the Paani Foundation so unique. If the villagers create the check dams , bandhs and tanks themselves, they are fully  invested in making sure they remain functional, which means they will continue to maintain them year after year.  This is in sharp contrast to projects done by the government, which typically decay over time because of a lack of ongoing support and follow up.

Also, since the villagers are intimately aware of their local geography, they are much better informed about what  needs to be done and where it needs to be done, as compared to a government engineer who is on a 4 year posting.

Far more importantly, this movement has the potential to become a great catalyst for social change. Because all the villagers need to get together on a single platform, they need to be able to overcome their local differences and unite - something which can be surprisingly hard, given the barriers which have characterized traditional Indian society for so many centuries.

Once they taste success, villagers get a sense of empowerment -  We did it ourselves ! This can then be the first step in a long line of social changes, because they have now learned that they are not helpless - they can do lots of for themselves if they get together. This can set off a positive virtuous cycle.  Once they have enough water and don't have to fight drought on a regular basis, they will have enough food, which in turn leads to an improved economy. This will then allow them to address their other social needs, such as education and health , without having to depend on government largesse.

What's great is that it's not just a top-down approach or a bottom-up approach - it skillfully combines both  !

It's not been an unalloyed success, and they have had setbacks and failures. I like the fact that they are dreaming big, but starting small. They're not in a rush, and are deliberately being systematic and slow , so they can grow properly and organically. They're making mistakes, and have the humility to acknowledge these , so that they can learn from them. They are happy to partner with funders , NGOs , geologists and water management specialists, so that they can scale up successfully.

Interestingly, they're not raising money for themselves - Aamir is independently wealthy and they have enough to run their Foundation. They're raising money in order to help villagers to accomplish stuff  which they cannot do for themselves. For example they need machines to do some of the heavy duty  construction work, and the donations they are raising are being used to hire the earth moving machinery for the villages. Also, since they do not want to handle the money themselves, the funds are being routed through an NGO , which has been certified by TISS as being eligible for CSR funding.

I like their thoughtful approach. They have been designed as a learning organisation, and are agile enough to deal with the problems and pitfalls they may encounter.

While many funders are happy to throw money at them, so they can replicate their work in other states of India, they have remarkable focus - as proven by their ability to say No to these requests. They don't want to bite off more than they can chew, and they want to be sure that their model is sustainable and scaleable . They are happy to share their SOPs with others, but don't feel they have the bandwidth to venture outside the state, because they don't want to dilute their impact.

Do you want to help ? They do have a list of scientific and technical problems they need help with tackling ( for example, using technology to map aquifers) , and your insights would be welcome !