Why IVF patients get confused

I received the above email from a patient. As you can see, he is a computer engineer, is doing his homework, and is very well organised !

This image highlights the fact that there is so much variation in the advice which IVF doctors give.
To add insult injury, except for the AMH level, all the other tests advised are useless and wasteful !
No wonder patients are confused !

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 IVF doctor's dilemma

I was confronted with an interesting dilemma recently. The patient had recently got married to an older man who already had three children from his first wife. This was her first marriage and she wanted babies, but she was already 39 . When she did a blood test , she found out she had ovarian failure , and would need to use donor eggs. She was quite comfortable with the idea because she wanted a baby desperately, but her husband put his foot down and said he wasn't willing to consider using donor eggs under any circumstances, because this was against his religious beliefs. She was extremely unhappy , and did her best to cajole him, but she wasn't able to persuade him.

She came back to me after a year's time and said, "This is what I plan to do. I'm going to ask him to deposit and freeze his sperm sample in your lab. I'm then going to come to Mumbai without him, and tell him that you superovulated me, collected my eggs ; created embryos with my eggs and his sperm; and transferred these embryos into me. In reality, you can use donor eggs instead of my eggs, and he will be none the wiser, because he will believe that the embryos were made with my eggs. This way, I'll get pregnant and have a baby; he'll be happy; and I'll be able to save my marriage."
She made it sound like a sensible solution , because it keeps everyone happy. After all, if he doesn't know we've used donor eggs, then why will he object ? After all, she is an adult, and is simply asserting her right to use donor eggs to have a baby.

The problem  is far more complicated, because she is married to him. We need informed consent when we do IVF treatment, which means both the husband and the wife need to sign the consent form.  I told her that if we don't get the husband's signature , we can't go ahead.  She said, "But he lives in Lucknow, and it's not convenient or possible for him to come down just to sign a form.  Why don't you give me the form , and I'll get his signature , and you can then proceed with  my treatment."
I have a suspicion she is going to do some hanky-panky, because she is so desperate to have a baby. She may forge his signature, and I can't countercheck whose signature it actually is - I am not a notary ! Once I have a signed consent form , I can then go ahead with the treatment, because I have complied with all the regulations.

However, I am worried that she is not being truthful with her husband. Now it's true that she's doing this in order to save her marriage , and she's not hurting him in the process.  When I asked her what happens if he finds out the truth after six years, she sensibly pointed out that the chances of his doing so are close to zero.

Doctors are confronted with these complex ethical dilemmas when we practice medicine, and it's very hard to find the right solution. It's easiest for me to refuse to help her. I can put my interests first, and turn her away, because her husband does not see eye to eye with her. This would protect me, but it would not be the best solution for her, as she would be doomed to remaining childless all her life.
I could also say - " I have an informed consent form, which means I have complied with the letter of the law . I can go ahead with the treatment and help her to have the baby she so deeply desires". But would this be ethical ? Now I can justify my actions by saying I am doing this in the patient's best interest - having a baby would add meaning and joy to her life, and would help her to save her marriage. On the other hand, the counterargument could be that I'm doing this just in order to earn more money !

How does one sort these things out? How does one parse them? If things go well , there's never a problem, but what happens if they have a dispute and need to go to court after five years ?  No matter how good my intentions may have been, no one willing be willing to accept that I treated her without any selfish interest. Both the lawyer and the judge will paint be as being an unethical, greedy doctor, and give me a hard time.  Why should I take on that risk , for no personal benefit at all, other than the fact that I want to help my patient?

#LaughAtDeath

The difference between a chemical pregnancy and a false pregnancy.

We often see patients who have done an IVF cycle elsewhere, and who get a positive pregnancy test result. They are ecstatic  when they are told by the doctor that they're pregnant. However, their HCG levels are usually between 30 mIU/ml - 100 mIU/ml or so, and they never cross more than 100 mIU/ml.  They may increase a little bit , and they then drop. The ultrasound scan never shows a pregnancy sac, and they never end up with a baby.

This is the story line their doctor feeds them.  You had a chemical pregnancy.  What this means is that your IVF cycle was successful, and the embryo we transferred for you did implant, but unfortunately, you miscarried. This was a very early pregnancy, but the fact that you got pregnant means my IVF treatment worked ! Don't worry  , we will do another cycle for you, and I am sure it will work this time.  We will run some special tests to find out why you miscarried, and change your treatment accordingly , so you have a better chance  of having a baby the next time. They then order expensive tests such as  ERA (  endometrial receptivity assay ) , NK cell tests; PAMP tests and TB PCR tests , to convince patients that they are on the right track.

The tragedy is that it's very easy to cheat patients by exploiting their ignorance, which is what these doctors are doing. When I review the medical records, I find that these doctors routinely give all their patients HCG injections ( such as Sifassi , Choragon  and Ovitrelle) after the embryo transfer .
Now if you give the patients an HCG injection and then do a blood test to measure her HCG levels, of course the HCG test is going to be positive. We could her husband pregnant as well by giving him the HCG injection !  This is not really a pregnancy, and it's definitely not a chemical pregnancy. It is what I call a false pregnancy or a pseudo-pregnancy - a pregnancy which is created artificially by giving an HCG injection in order to fool the patient .

Please don't get taken in for a ride. If your doctor wants to give you an HCG injection and then do the HCG test, you should worry a lot  !

Not sure your IVF doctor is giving you good advice ? I am happy to give you a free second opinion to help you ensure you are getting good medical care . Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

The insecurity of poor quality IVF clinics

A patient asked me for a second opinion after a failed IVF cycle .

I asked her to send me photos of her embryos, so I could provide personalised advice.

She sent me this email.

I tried to get the photos, however this is the reply from the embryologist. Should I be concerned about continuing at this clinic?

 We do not have any pictures of the embryos. We did not have to hatch either embryo because they were already hatched for PGD. When we thaw the embryos we only take pictures if we hatch because it is the same machine. We do not want to keep the embryos out any longer than they have to because we do not want to expose them to any outside influences that can effect them such as pH changes, temp changes, and large amounts of lights.

This is not a good answer. All good IVF clinics take embryo photos routinely. Even when the embryologist looks at them , they are being exposed to the same " large amount of light", so this reason makes no sense to me Patients need to start getting more proactive if they want to make sure they are taking treatment at a good IVF clinic.

Want to make sure your IVF clinic is following best practices ? 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 can we prevent doctor bashing ?

Now that the doctors have gone back to work, everyone is breathing a sigh of relief. The government is very pleased that they have averted a crisis, and that patients are being looked after once again; and the junior doctors are pleased that they can go back to completing their education and getting their degrees. One more storm has been weathered successfully.

However, what's very disappointing is that no one is stepping back to look at the big picture. No one has bothered to do a root cause analysis as to the reason for this simmering anger against doctors; and there has been practically no public support for these young residents, who have been hung out to dry for having the courage to demand protection for themselves - something which is their basic right, and which they should be able to take for granted.

The tragedy is that strikes and agitations by junior doctors have become recurrent events . I remember that when I was a resident 30 years ago, we had also gone on strike , and the government broke us by wearing us out and threatening us . They are playing exactly the same game again - it's just the names of the players who have changed.

All the junior doctors asked for is that the administration provide them with enough security , so that their personal safety is not endangered during the performance of their duty. Is this too much ask for ?

To add insult to injury, even the High Court Chief Justice threatens the doctors when they sought protection ! She  said - Public will hit you': Resume work or face termination, Bombay HC tells striking resident doctors. It's very sad that a judge is suggesting that it's OK for citizens to break the law and beat up doctors!

Things have gone from bad to worse in the last 30 years . The living conditions the government hospitals provide for these junior doctors remains deplorable. The support infrastructure is completely lacking ; junior doctors are chronically overworked and sleep deprived; and they are made to do a lot of useless scut work , because the hospitals refuse to spend money on the ancillary staff required to provide good patient care. It is the poor junior doctors who are saddled with this additional burden - something which is not part of their curriculum or job description, because it doesn't involve delivering clinical care to the patient. The tragedy is that because these young doctors are conscientious and responsible , they are willing to take on these additional duties, even though they shouldn't have to, simply because they want to make sure that their patients get better.

Thus, they waste hours carrying blood samples from the ward to the laboratory ; or collecting reports from the x-ray department , rather than learning at the patient's bedside . This is stuff that should actually be done by ward boys, assistants and clerks, but because the hospital doesn't have the budget to employ them, it's the junior doctors who are treated as beasts of burden, and forced to do these mundane administrative tasks. What's really appreciable is that they do this unquestioningly and uncomplainingly, because they respect their seniors and professors, and will do whatever they ask them to.

No junior doctors ever says, "No, this is not my job , and I refuse to do it " - though they would be well within their rights to do so. This is also partly because of inertia - this is what their seniors did, and this is the way things have always been. However, the truth is that this is a broken system, and we cannot continue like this.

The underlying reason for this sad state of affairs is that the government loves to make populist declarations as regards medical care. Thus, they promise to provide free health care to everyone, even though they don't have enough hospital beds and doctors to be able to do so . This sounds great on paper , and gives the ministers a lot of press coverage. However, the problem is they don't put their money where their mouth is. They don't back up their promises by spending money on employing additional staff in the hospitals; or providing the hospital dean with a budget which is sufficient for him to be able to ensure that the aging medical equipment in these hospitals continues to work properly. Even basic medicines are not available in the pharmacy, and patients are made to run around from pillar to post. It's easy to see why patients in these government hospitals lose their temper - the system is so badly designed, that anyone is bound to get agitated, upset, and frustrated trying to navigate it. However, patients can't vent their anger on the people who deserve their ire - the politicians and administrators, because they are inaccessible.

This is why it is the junior doctors who end up serving as punching bags whenever anything goes wrong. It's high time that we accept that these problems do not arise because junior doctors are careless ; lazy ; or don't want to work. Let's not forget that medical students are our academic creme de la creme - they are the best and the brightest our educational system produces, and they have worked hard to get into medical college. They continue to be willing to slog hard, and do so no matter how adverse their working conditions are.

The reason for the doctor bashing is because the system is dysfunctional and broken ; and unless we are willing to spend enough money to make sure that the citizens of this country get good quality health care at an affordable cost, things are just going to progressively become worse. The reality is that the administration continues to ill-treat them with impunity, just because they can do so easily. They are a floating population, who are very vulnerable, because they know that their careers are at stake, and they don't want to risk this.

My big worry is that the government doesn't seem to understand the long-term consequence of ignoring the legitimate claims of doctors. Bright students will no longer want to join medical college after seeing how badly doctors are treated by the administration, the media , and by angry relatives. A medical college seat used to be highly coveted. It will now go to the B-graders, because the A-graders will look for greener pastures and opt for other careers. Most parents will also discourage their students from taking up medicine - a very far cry from the past, when parents would be exceptionally proud if their children secured admission in medical college because this was so highly competitive.

Please stop and think. The message are we conveying to these young doctors is that we don't care about your personal safety - you have to go back to taking care of patients, no matter the risk to your life and limb . If we treat them so inhumanly, how can we expect them to become humane doctors and care for their patients when they graduate.

Instead of allowing the poor doctors to remain convenient scapegoats, we need to speak up and make sure the government authorities are held answerable for improving medical infrastructure . The government has more than enough money - it's just that corrupt officials and bureaucrats pocket it , as result of which patients are deprived of basic medical facilities. This is what we should really be agitating against - but because affluent citizens like you and me get our care from private medical facilities, we don't care if the government allows the public hospitals go to the dogs.

Today, tempers have cooled, and the medical associations and the government have come to an understanding. We've weathered the crisis for now, but I think it's just a matter of time when it will blow up again. The next time another doctor gets beaten up by angry relatives , we will have a sense of deja vu, but whether this incident will occur in the next week, or the next year, I cannot predict.

Iatrogenic infertility - when infertility doctors cause infertility !

Being infertile is bad enough, but it's a hundred times worse when the infertility is actually caused by your doctor. This is what we call Iatrogenic Infertility and it is of two types. One is permanent , where your fertility is damaged irreversibly because of something which the doctor does. The second is temporary, where your fertility takes a beating because of the medical intervention he advises.

Permanent damage is usually because of surgical procedures. The three commonest offenders in this regard are
hysteroscopic metroplasty;
laparoscopic ovarian drilling;and
laparoscopic surgery for treatment of endometriosis.

Let's look at these one by one.

A hysteroscopic metroplasty is an operation which is done only by Indian gynecologists . For some weird reason, they feel that infertile Indian women have a small uterine cavity , and they make cuts in order to increase the size of their uterine cavity. This is completely ridiculous, because every woman, no matter how fertile she is, is obviously going to have a small uterine cavity when she is not pregnant. Nature has designed the uterus so that the cavity will automatically grow once she gets pregnant, so this is a completely pointless procedure. However, it's become extremely popular, simply because most gynecologists have itchy fingers - they are happy to put in telescopes wherever they can, including the uterus. It's easy to convince the patient to do this hysteroscopy procedure, because they call them " minimally invasive" , thus giving the impression that there's very little risk involved. Once they put the telescope inside, they always want to do additional procedures so they can charge more, and the commonest "add-on" is a metroplasty. This is done for the flimsiest of pretext, "Oh, the cavity doesn't look fine. It's a little bit narrow. I can't see both the cornu, so let me make a few cuts to fix the problem - all kinds of funny reasons. The harm is that these unnecessary cuts can cause scarring , and damage the endometrium. The irony is that these scars cause the cavity to shrink, so that patients become infertile because of a procedure which they didn't need to do in the first place !

The second common offender is laparoscopic ovarian drilling, where doctors drill holes in the ovaries for women with polycystic ovarian disease. Now, if this is done sensibly  ( restricted only to women who have large ovaries, with increased stroma; and performed conservatively ( only 3-4 drills per ovary), it can be helpful. However, many over-enthusiastic doctors end up burning and destroying too much ovarian tissue in these women. They end up causing ovarian failure in these poor unfortunate women , who started off having lots of ovarian reserve , but are now doomed to being infertile because their ovarian reserve has been damaged. That's especially true when some doctors repeat the surgical drilling , because they don't think the earlier doctor did a good job !

Finally, laparoscopy for endometriosis often causes a lot of harm. It's especially tragic because these patients don't require a laparoscopy in the first place ! The trouble is that in their enthusiasm to destroy the endometriosis, they often remove normal ovarian tissue, causing the woman to become infertile , and pushing her from the frying pan into the fire.

Temporary infertility is usually because of medical interventions.  The commonest problem is when women are put on anti-TB treatment because of a positive TB-PCR tests. They end up taking these toxic drugs for nine months. Often patients get so fed up , that they drop out of infertility treatment, thus depriving themselves of their chances of having a baby. This is also true for patients who are subjected to multiple IUI cycles . Every new doctor wants to repeat the old IUI treatment once again , either because they don't have anything better to offer , or because they feel that the IUI done by the earlier doctor wasn't good enough. By wasting a lot of the patient's precious time, they reduce her ovarian reserve because she ages, and this ends up compromising her fertility. Most of these patients are not willing to do an IVF cycle, because of the repeated IUI failures, as a result of which they have no confidence left in infertility doctors. Even if she does finally screw up her courage and do an IVF cycle, her ovarian reserve has dropped because she has become older, and this reduces her chances of getting pregnant even with IVF.

If you want to make sure that your infertility doctor does not add to your infertility problems, you do need to do your homework !

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 junior doctors in India are running scared

Protecting doctors against medical terrorism

Futile overtesting after an IVF cycle has failed.

A failed IVF cycle can be extremely traumatic for the patient because you do it with a lot of hope knowing that that's your best option. It's the court of last resort after all, and when the cycle fails you're world goes to pieces because you're not sure what to do next, you really don't have a backup option. This is why when a cycle fails, the first question every patients asks is, "Why did it fail?" The doctor in an obvious knee-jerk reflex response will say, "Okay fine, we'll run some tests in order to find out."

Now this seems very logical, but actually this is a very poor quality question which ends up resulting in a lot of over-testing and a lot of over-treatment, because the fact of the matter is, we really don't have very good tests to be able to find out which embryos implant, and which don't. This is hardly surprising because you're putting a microscopic ball of live cells into the uterus, it's very hard to track it's fed. Ideally, doctors should be honest with patients and say, "Look we can't answer that question" but obviously patients don't want to hear that question, and very few doctors are mature enough to be, respect their patient's intelligence and share the truth with them, so therefore they will come up with all kinds of possible reasons such as immune rejection, or NK cells, and do all kinds of fancy, exotic, expensive esoteric tests. Which then lead the patient up the garden path because not only do they make a waste a lot of money, obviously these test results are abnormal as they often will be, they then need to be treated.

The irony is really doing anything for any of these abnormalities doesn't really increase the chance of the patient conceiving in the next cycle. Patients need to understand that's easy to ask questions but sometimes the right answer is "We don't know" and in one sense it really doesn't matter because often, all we need to do is to repeat the cycle, make sure the embryos are gorgeous, the endometrium is fine, and the transfer is easy. If we do this a sufficient number of time, the chance of finally getting pregnant are going to be excellent. But it does require a lot of patience, both on the part of the doctor, as well as the patient, and it requires a lot of maturity on the part of the patient to be willing to accept that technology doesn't necessarily have answers.

This of course makes patients very uncomfortable because they want a doctor who's omniscient, who can answer all their queries, and it's not very comfortable knowing that there lots of things which are not in a doctor's control, but we need to accept that human reproduction is not efficient and we need to learn to live with this reality.

I always tell patients, "If there really were a test which would help me to find out why your cycle failed, don't you think I would do the test before the cycle failed, so that I could optimize your chance of getting pregnant and increase your chance of success, rather than wait for the cycle to fail and then do the test?" This is why all these tests after a failed IVF cycle are completely futile and wasteful.

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 !

After the IVF cycle fails

I just got this email from a patient.

My wife is suffering from PCO. We are trying for a baby for last 7 years.My wife's AMH is 6.95. We recently opted for IVF but it failed. Our doctor was happy with the stimulation. 12 eggs were retrieved and seven were fertilised. They carried out third day embryo transfer. Embryologist claimed that all embryos were of very good quality. They transferred three embryos.But now they say that my wife's eggs are of very poor quality and that is why the cycle failed. . Now we are confused about what to do next.

This is a very common problem. Doctors are hopeful and optimistic at the time of the transfer. However, when  the cycle fails, they blame the patient for the failure.

They come up with all kinds of creative reasons ! Either the eggs were bad, or the sperm were abnormal, or the lining was thin, or the immune system "rejected " the embryos.

Patients understandably feel cheated when the doctor sings such a different tune after the cycle has failed, and this is why they find it hard to trust IVF doctors.

We need to protect our resident junior doctors

Resident doctors occupy a unique place in the medical profession. On one hand, they are still students, who are learning the art of practising medicine . They have to keep their professors happy, and also master the content in their textbooks , in order to pass their examinations. However, they are also responsible for delivering care to patients. Theoretically, this is supposed to be done under the supervision of their seniors, but because there is a shortage of qualified professors, they are often forced to fend for themselves. They are paid a pittance, because this is treated as a stipend, and not a salary. They form the heart and soul of a teaching hospital, and are responsible for powering the medical care the teaching government hospitals provide to their patients in real life. Because they know that medicine is a hard task-master, they uncomplainingly work long hours in order to master the nuances of medicine. Sadly, the working conditions they are forced to labour in are pathetic. Hostels are dirty and poorly maintained; the mess which feeds them is a mess; and they remain over-worked and sleep-deprived , in order to make sure their patients are well looked after. 

They are forced to make life-and-death decisions, often without adequate supervision, in the middle of the night, because their seniors are sleeping comfortably in their beds. However, they put up with all this, because they respect their professors; and are willing to work like dogs , because they want to become good doctors when they graduate.

The working conditions for doctors in government hospitals have remained deplorable since I graduated 30 years ago. However, what's changed is that the residents are now scared to take care of seriously ill patients during emergency situations. They are worried that they will get beaten up by the family members in case the patient dies, and no one will protect them. There have been so many incidents of unjustified violence against resident doctors in the past week, that the junior doctors have finally had the courage to get together, take mass leave, and approach the High Court , to pray for protection during the performance of their duties. The healthcare system has reached a breaking point , because we have let our young doctors down.

One would expect the High Court to be empathetic, and stand up for these vulnerable young junior doctors , who are our future doctors of tomorrow. All they are asking for is that the administration provide them with adequate security cover, so that they don't get bashed up by irate relatives; and that the government implement the Maharashtra Medical Services Persons and Medical Institutions (Prevention of Violence & Damages or Loss of Property) Law, to ensure that people who beat up doctors are given the punishment they deserve .This law specifies that an assault on doctors is a cognisable and non-bailable offence , but the police have been very lax in implementing this . The junior doctors simply want confidence that they can work without the threat of being at the receiving end of violence from the patient's family members. Is this too much to ask for ? They deal with life and death issues on a daily basis, and it's the duty of the government and the administration to provide them with safe and secure working conditions.

Instead of ordering the government to implement the law, the High Court has actually threatened these doctors that they may lose their jobs if they don't go back to work. This is so short sighted ! Ordering doctors " to be compassionate to their patients" when we show such little compassion to them is hardly a just or fair solution. All these young doctors want to do is to be able to provide the right care to their patients, without feeling vulnerable and exposed. They want to graduate with their limbs intact, so they can start practising medicine , and serve society as respected doctors. 

It's ironic, but I remember that when I was a resident doctor over 30 years ago, we had gone on strike for 3 weeks, requesting that we be provided with decent working conditions ( clean quarters and healthy food) so that we could take better care of our patients. The government made a lot of promises, but nothing was done at the ground level. The tragedy is that there is very little unity amongst resident doctors. They have limited funds because they are students, which means they cannot afford to hire senior counsels to argue their case; they are dispersed across many hospitals; and they are a floating population, in the sense that they remain resident doctors only for a few years. Once they graduate and start practise, they are no longer resident doctors, and can no longer fight for their cause . The tragedy is that not only have they been hung out to dry by the government and the judiciary, they have also been abandoned by their seniors - their professors, and the entire medical profession itself. Most practising doctors are just making anguished noises on social media about the ill-treatment being meted out to residents, but we have done precious little to actually ensure that these residents get their basic right to work under safe conditions. The administration has failed them - and so has everyone else !

If they are forced to continue running scared while performing their duty of trying to snatch critically ill patients from the jaws of death, then what kind of doctors are we creating for our future ? Why would they want to become doctors at all ? Imagine if you got beaten up, or you saw your friend getting thrashed, just because he was trying to save a seriously ill patient in an emergency . Would you be willing to stick your neck out and try to save the next moribund patient who came to the hospital ? Or would you worry more about saving your own skin ? The tragedy is that well-trained doctors can make a world of a difference to ill patients in the ICU and the ER - but they will now no longer be willing to work in these high- risk settings any more, because they don' t want to risk their own life and limb. Soon doctors will all prefer becoming skin specialists, so that don't have to worry about being bashed up by the relatives of critically ill patients !

Just like factory workers need protection from hazardous machines and unsafe working conditions, doctors need protection too ! As it is, they are stressed, overworked, tired, underpaid and under-supervised. It's not fair to expose them to the risk of violence because the administration has not take adequate security measures. Junior doctors also have a constitutional right to safe working conditions, and it's the job of the legal system to ensure than the administration and the government provides them with the safety and security they need to be able to provide proper care to their patients. The present conditions are deplorable , but if the judiciary and the government continue to browbeat and bully these vulnerable and scared junior doctors, whose careers are at stake, then the future of the entire medical profession is at risk.

Treating the anti-doctor violence epidemic in India

The epidemic of violence which has erupted against doctors all over the country has taken everyone by surprise. In the past, doctors used to be respected and trusted . Today, it seems to be open house on doctors , and anytime a patient suffers a complication,  goons are taking the law in their hands and mercilessly thrashing the junior doctors who are on duty .

Doctors are running scared. They don't trust their patients anymore , and are on their guard. They're wary , and are no longer willing to treat critically ill patients  - exactly the kind of patients who desperately need urgent medical attention.  They would  much rather transfer them somewhere else in self -defence, because they're scared that if something goes wrong, they will have to put up with both verbal and physical abuse from angry relatives. They don't want to take this chance anymore, because they've become the whipping boys for no fault of theirs.  Doctor's whatsapp groups and social media channels are full of anguished messages from angry and upset doctors, who feel they are being targeted for no fault of theirs.

If a patient is critically ill, there's a very high probability that patient will die, no matter what the doctor does.  Why do relatives vent their ire on the poor junior doctor who happens to be on duty ? Most young doctors are  doing  their best, inspite of the pathetic working conditions they are forced to put up with in government hospitals. There is a shortage of medical staff and they are forced to work overtime , no matter how sleep deprived they are ; the infrastructure is creaking; there is inadequate supervision by senior professors, who are not available during emergencies ; and the equipment is either old , missing or malfunctioning. Doctors feel very helpless and vulnerable , because no one in the government is willing to do anything to protect them. Although there is a law which is supposed to protect them, it is never implemented in real life, and this governmental  inaction is just making a bad situation worse.  The situation has come to a boil, and  lots of doctors have started treating patients as potential adversaries . Trust between doctors and patients is breaking down, and patients are going to get hurt when this happens.

Government officials are surprisingly apathetic and unhelpful. They refuse to allow doctors their democratic right to protest, and the only solution they have to offer is to advice hospitals not to allow more than  two relatives  at a time; to limit visiting hours ; and to employ more  security guards !
Here are two simple things  which hospitals can and should do on a priority basis.

Hospitals need to implement a Code Purple emergency response team. Any time any medical staff member feels that  things seem to be getting out of hand - for example, when a patient is seriously ill , and the visitors are starting to get rude and restless, and a mob seems to be collecting, they should activate a Code Purple alarm. When this is sounded, everyone who is on duty in the hospital  -  nurses, clerks, peons, ward boys, security guards, and senior doctors - should drop what they are doing; call the local police ; and come instantly to help the junior doctor in his time of need. This is something which has been successfully deployed in a hospital in Pune, where it has successfully helped to prevent any incidents of abuse of the medical staff for many years. The hospital management should have a zero tolerance policy for staff abuse; and security needs to be beefed up.

It's also equally important that the hospital management insists that senior doctors must remain on duty 24/7. They can shield  doctors from the wrath of the relatives. One of the reasons relatives get so angry when their patient is critically ill is because they can't see a senior doctor on the premises. They are understandably upset that the care of their patient is being delegated to a young  inexperienced junior doctor , who is completely raw , and is not sure how to handle serious patients. When a junior doctor informs relatives that their patient has died; or is dying ; or needs to be transferred, they are very resentful that there is no senior doctor available to take care of their patient. This is when they start breaking things and beating up doctors. The presence of a senior doctor can change everything. An experienced dignified doctor with  gravitas can talk to them, and calm them down. He has years of expertise, and knows how to deal with angry patients. He can establish a rapport, and his dignified presence will make a world of a difference, because the relatives can see that the senior medical A team is on the job, and is doing their best to save their patient. They will be much more understanding and forgiving. I find it quite remarkable that no has remarked on the fact that no senior doctor was available on the premises during all these episodes of medical violence. If there had been one, matters would never have come to such a pass. This is the least we can do for the sake of our junior doctors. It's very unfair to leave them exposed and vulnerable.

A free, simple, fun, effective way to improve your fertility !

Here's the prescription - Have more sex !

Now, this might seem surprising. After all, sex is such a natural activity and everyone does it all the time , so how will having more sex improve your fertility ?

The trouble is that sex for procreation is very different from sex for recreation.

When you're made to perform " on demand ", this creates all kinds of problems.

The husband may not feel like having sex on a particular day , but his wife arm twists him , because the doctor has advised them to have sex on Day 12, 14 and 16 ( which is actually bad advice, but is still trotted out mindlessly by most gynecologists. )

This often means that he fails to get an erection on that day, which makes his wife really angry and upset, because she blames him for "wasting" her fertile day and messing up her chances of getting pregnant in that month.  ,  This starts becoming a negative vicious cycle , because he feels that he's losing his potency , and won't be able to perform in the future as well. They start fighting with each other, which compounds the problem. The wife is completely detached from sex, because she has now divorced baby-making sex from love in her head . Because intercourse is no longer enjoyable for her , she does not get lubricated, and this causes dyspareunia ( pain during sex). They both start dreading the act of intercourse, which means the frequency drops even further !

In today's life , stress in omnipresent, and the loss of sexual desire is the price many couples pay for leading a high-pressure life. By the time people come back from home in the evening, they are dead tired. Coping with the daily commute, dealing with an irate boss ,and trying to placate angry customers often means that all they can do when they come back home is watch TV, have dinner, and flop into bed . They just can't find the time, energy or inclination to have sex on the weekdays. The weekends are so busy catching up on household chores that it's often months before they're able to have sex at all .

This is one of those issues which both are ashamed about. They don't want to discuss it, which means it becomes the elephant in the room . They don't even tell their doctor the truth , and will usually lie to the doctor about their frequency of intercourse. Most doctors aren't sensitive or empathetic enough to inquire into such a touchy and sensitive issue.

This is why a lot of what doctors label as infertility is actually just a result of infrequent intercourse. The problem starts getting medicalized , and doctors are more than happy to intervene , by doing procedures such as artificial insemination.  This means that the poor couple ends up converting a pleasurable bedroom activity into a clinical activity  - and to add insult to injury, they have to pay for this !

So what should you do? For one thing, stop timing baby-making sex. This is counterproductive , and just adds to your stress levels. The trick is to have sex frequently and not worry about the actual days. Human reproduction has been designed well enough that as long as the sperms are going in the vagina, you don't need to obsess too much about when you're having sex , as long as you are having it at least twice a week.

Yes, it can be hard to have sex when you're tired in the evening , so a simple solution is to get up and have sex first thing in the morning . Men will often have an early morning erection , and you can have a quickie - for example, while having a shower together. ( This is a good way of starting the   day !)

You should also experiment with using sexual toys  to improve libido. These are now easily available online , and help to create the mood . The wife can also work on seducing her husband in order to initiate sex - he'll be more than happy to reciprocate !

It's a good idea to use liquid paraffin , because that's an effective sperm-friendly lubricant , and can help to overcome dyspareunia . The husband can also ask the doctor to prescribe a Viagra equivalent. He can use this as a crutch, in order to help him get a harder erection, and this can help with vaginal penetration.

Couples need to put having sex on their priority list  - after all,it's not something which you can outsource to someone else !  The tragedy is that always important , but never urgent , which means it it keeps on getting pushed off.

In order to persuade patients, I remind them that if you don't have sex frequently with your wife, you will have to pay a doctor to do artificial insemination for you . This would cost more than Rs 20,000 every month ( forget about the inconvenience of going to the doctor; the time wasted; and the indignity of your wife being prodded and probed) . If you instead decide to prioritise having sex with your wife at least seven times in a month ( before ovulation), then you will save all that money.This means you are actually  being paid Rs 3,000 rupees to have sex with your wife every time! Now, isn't that a good deal?

Baby making sex can be fun and pleasurable , if both of you are willing to work together.
One simple way of keeping the pressure off is by not insisting on having vaginal intercourse every time. You could just cuddle and mutually masturbate each other - and often this will lead to sexual intercourse in the heat of the moment. 

How IVF doctors cheat IVF patients

I just got this email from a patient, and it made my blood boil.

I have been reading your blogs in my 2ww. It was my first ivf cycle. Attaching the details. I had my beta hcg today which was less than 2. My gynae says in few cases repeat test can show positive results. She has continued progesterone, progynova and medrol and two hcg injection - one today and another on 18.is there really any scope. Let me know if you require any additional information.

I hate it when doctors take patients for a ride. A negative HCG 14 days after the egg collection clearly means the cycle has failed and she is not pregnant. 

Read more at www.drmalpani.com/knowledge-center/articles/hcg

The doctor should be honest with her and tell her this. However, she is creating false hope in her, by telling her that in some patients, a repeat HCG test can show positive results. This is a lie.

What's even worse is that she is fooling her. 
By giving her the HCG injection, she is making sure her next HCG blood test will come back as positive , as a result of the HCG injection she gave her. She will then tell the patient that the IVF cycle was successful, but she miscarried; and will cajole her into doing another cycle again.

I hate it when doctors take patients for a ride, because these doctors give all IVF clinics a bad reputation !

Resident doctors being beaten up by relatives in a hospital in Maharashtra

No wonder the doctor-patient relationship is at a nadir !

IVF doctors should stop advising unproven treatments to their patients

An excellent paper, authored by some of the world's leading IVF clinicians, appeared in Human Reproduction, the leading IVF medical journal, in Jan 2017.

Adjuncts in the IVF laboratory: where is the evidence for ‘add-on’ interventions?

"Those advocating and recommending unproven procedures to their patients must ensure that they fully inform the patient of the evidence for its safety and effectiveness orally and in writing to ensure that people considering treatment using adjunct therapies are in a position to make an informed decision. It is also important that all procedures performed, including the adjunct treatments, are well-documented and followed up."

The unproven treatments described in the paper include:

Embryo glue
Sperm DNA fragmentation
Time-lapse imaging
Preimplantation genetic screening
Mitochondria DNA load measurement
Assisted hatching

The problem is that most IVF clinics are private, for-profit businesses, which are happy to exploit their patient's ignorance. This is why they merrily continue to offer expensive , unproven treatment options, in order to maximise their profits.

If your doctor prescribes these " treatments" , without telling you they are experimental and unproven, then he is using you as a guinea pig. If you don't want to pay for the privilege of being one, then you should refuse these.

IVF patients need to learn that doctors don't have all the answers

Dear Dr Malpani,

I read your recent email with interest, as it relates directly to me.

After 5 years of IVF and only one successful transfer, which occurred last year at the age of 49 (2016) and I was pregnant for 11 weeks. Unfortunately the embryo failed at 11 weeks due to Edwards syndrome, but these were my own eggs from about age 46.

Since this, I have now done two transfers with donor eggs (23 year old donor) and neither has worked.

The only successfully pregnancy I had involved a treatment protocol designed by a fertility immunologist, as a result of extensive and expensive blood tests in the US (exactly a you describe - the only place they can be done is in Boston).  This treatment included Intralipid infusions, neuprogen injections, prednisolone tablets, clexane injections, as well as estrgoen patches and progesterone pessaries and then once I reached 6 weeks I had to have progesterone injections every second day (to keep my levels up).  NK cells are vey high, along with other immune issues.

From reading your email you are obviously very skeptical of this type of treatment, as I am also.  Not only is it expensive, time consuming and stressful, I also have many Dr's who say they do not believe it because it is untested and fringe.  However, as this is the only time I have achieved a positive pregnancy test, it is very hard for me to question the treatment protocol.  I have used Chinese medicine for the last 5 years, acupuncture, changed my diet to gluten free and reduced sugar intake.  I have read and followed many different people, as well as doing conventional treatment and none has achieved a result for me.

We now have 3 embryos left, made with the donor eggs.  We do not wish to waste these last few opportunities, so I am looking for your second opinion on what to do.  I have had Endometriosis removed from around my bowel, two surgeries for Ashermans syndrome (which were successful and confirmed with a hysteroscopy a year ago), I also have many fibroids but all outside the uterus.
The immune specialist believes the Endometriosis could be back and most likely the main cause of the implantation failure, along with the other immune issues.  He has asked for me to repeat the expensive blood tests ( a smaller panel of tests, as my last tests were over two years ago).  These results will take up to 6 weeks and then we will provide an analysis and a protocol to plan for the next transfer.

I am confused and skeptical, but also as your email says pretty desperate for answers after so many years and only one successful transfer.  These are the last embryos we have to use, so the last opportunity to get a result.

The Dr in Spain (where the embryos are) has suggested a Depot injection to block my cycle for 3 months, in order to reduce inflammation and then start again after that - preparing my system artificially with Estrogen patches and progesterone pessaries.  Which is just more of the same, what was done the last two cycles - which did not work.  I do not believe my lining was good enough (7+mm) and having just had a period after the negative pregnancy test which lasted for only one day - I believe that confirms the lining was insufficient.  I am told that is not an indication, but that is the smallest bleed i think I have ever had.

The US immunology Dr says I should not take the Depot  injection, this is not the right thing and they only suggest that as it is all that they know.  He wants me to re-do the blood tests, which I agree at least gives him a picture of where things are right now.  Then he will suggest a course of action.

What is your opinion?  Which action should I take.  Time of course is of the essence, so I need to make informed decisions based on thorough information.  As your article states, this is very difficult to find and from a lay persons perspective it is literally a mind field out there.

I value your thoughts and second opinion on my case.  If you need any further information, please let me know and I will send it through.

Thanks and regards,

This was my reply to her


I sympathise with you -  medical ignorance can be extremely frustrating.

As you know, I do not believe either the endometriosis or the immune issues affect implantation

The fact that you got pregnant after the "immune treatment protocol" could very well just be a coincidence

I wish I had more scientific answers to give you, but I will not pretend to know more than I do

Why good looking embryos do not implant is still one of those things we do not understand - it is
one of medicine's unsolved mysteries !

Human reproduction is not very efficient - and both IVF specialists need to make our peace with this unpleasant  fact of life.

I am a conservative doctor, and don't believe that more is better - unlike a lot of "immune therpaists" in the field of IVF. To each his own

What was your uterine lining thickness ? A thin lining will definitely reduce the chances of implantation. How and why did you develop Asherman syndrome ?

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.

What can we do get doctors to answer patient's questions ?

One of the commonest complaints patients have about doctors is that they don't bother to explain anything to them. Most of their explanations are short and sweet - curt and to the point. They're full of medical jargon, which means that the patient usually doesn't have a clue what the doctor meant. However, most just nod their head whenever the doctor has finished talking , so that the doctor assumes that the patient has understood everything he's told him.
This brings us to the key question - if patients don't understand what the doctor is saying, then why don't patients ask doctors more questions? After all, they know it's important for them to understand what's happening to their body ! I find it quite surprising that even extremely intelligent professionals ( such as CEOs and lawyers ) are often tongue tied when talking to a doctor. It's not as if they don't have any questions, or that all their questions have been answered - it's that they are often scared to ask them.

Part of this is because they feel that the doctor is very busy, and they don't want to eat into his time  - after all, he has lots of other patients to see.  However , a lot of this is because of the doctor's body language. Patients are very aware of the doctor's non-verbal signals, and they can sense that the doctor may not take kindly to being grilled further. It's pretty obvious when the doctor signals that he's said everything he wants to say, and that more questions are not welcome. He wants the patient to move on, so he can move on to seeing his next patient.  Doctors are in a hurry to terminate the consultation , and most doctors prefer compliant patients , who are happy to do whatever he says . Doctors don't like patients who pester them with lots of questions, and they make their unhappiness very clear.

Also, patients are worried that the doctor may think they are stupid if they ask very basic questions,  which is why they bottle them up. Some go to Dr Google to try to find answers, but this means that they often get confused or lost , because they cannot assess the credibility of websites. This causes even more frustrating, and this is why patients complain about their doctors' inability to communicate, especially when things go wrong.

The fact of the matter is that doctor patient communication is a two way street. Patients also need to learn to speak up, rather than leave everything up to the doctor. After all, their doctor can't read their mind, and if the patient says they don't have any other questions, what's the doctor supposed to conclude? Patients need to remember that the only stupid question is the one they don't ask !

Yes, it's true that the locus of power lies with the doctor, and that there is a lot of information asymmetry. The patient feels vulnerable, and is scared to ask questions because he doesn't want to upset the doctor. He's worried that the doctor may get irritated if he asks too many questions, and therefore he thinks it is safer to keep quiet. 

However, if a doctor feels that he's done a good job with communicating with the patient simply because doesn't ask any questions, then he's just fooling himself. The truth is that silence does not doesn't mean that the patient has understood everything you've said ! Doctors need to be far more proactive in encouraging questions from the patient. 

Many doctors are scared that this will consume a lot of their time , but it's far better to clear the patient's doubts rather than let them fester. These shortcuts will come back to haunt you later if anything goes wrong, which means that your impression that you have saved time by not answering their questions is completely illusory.

Tragically, today it's usually only the doctor who is the one asking questions during the consultation!  We need to flip this around. The good news is that a lot of patient education can be done digitally - both before the consultation; in the clinic; and after the patient has gone home.  This is what will actually save the doctor time - and also ensure that the patient has understood everything the doctor has told him.

Why we should do only Day 5 transfers for poor ovarian responders

Lots of clinics do Day 5 ( blastocyst)  transfers, but they  usually reserve them for patients with a good ovarian response - patients who have good eggs and lots of embryos , because they're pretty confident that they will get Day 5 embryos. However, they will use double standards when they're treating patients with diminished ovarian result. These are patients who have few eggs and few embryos and they're very scared that they may not get any blastocysts. This is why they will usually transfer their embryos on Day 2 or Day 3. These justification for this is as follows - If we only have two embryos on Day 3, then why bother to grow them in vitro to Day 5?  Let's go ahead and transfer them on Day 3 itself.
Interestingly, these doctors agree transferring blastocysts is a better option. Blastocysts have a better implantation rate as compared to Day 2 or Day 3 embryos; and blastocyst culture allows the doctor to choose the best embryos to transfer.
Their argument is that if you only have two embryos, then a blastocyst transfer offers no advantage as far as selection is concerned . The reality is that they don't want to risk taking the chance that the patient may not have a transfer at all, if  her embryos arrest in the IVF lab between Day 3 and Day 5.
I think this is very shortsighted. If an embryo is going to become a baby when you put it back in the uterus, it first has to form a blastocyst inside the uterus. If the IVF lab is decent, then if it's going to form a blastocyst in the uterus, then of course it will form a blastocyst in the lab as well.  They why is the doctor scared about growing this embryo in the lab? Is it because he doesn't have enough confidence in his lab?
Another argument which has been trotted out is that growing to blastocyst doesn't improve pregnancy rates in these patients with poor ovarian reserve. This is flawed , because the point of an IVF cycle is not just to improve pregnancy rates.  The truth is that the pregnancy rate will remain as good even when you grow them to blastocysts in a good lab, so this will not reduce the pregnancy rate. However, much more importantly , you're also utilizing the IVF cycle to provide valuable information for the future.  Let's look at this more carefully.
If the patient gets pregnant, that's a happy ending, irrespective whether you did a Day 2 or a Day 3 or a Day 5 five transfer, so there's no point in discussing that outcome. But if the patient doesn't get pregnant after you transfer a single good embryo on Day 3, then the poor patient is not sure what to do in the next cycle.  She is not sure why her cycle failed because you transferred so early. Why did the embryo fail to implant? Was it a problem with the embryo?  Did it arrest inside the uterus after the transfer ? Or was it a problem with the uterus? Should her next step be surrogacy? or should it be donor egg IVF ?
She's completely confused, especially since you've made a good Day 3 embryo for her . You have sparked some hope in her heart, and she was very hopeful that the embryo you put back would become a baby. Not only has she had to suffer through that terrible two week wait, she's actually no wiser as to what to do in her next cycle.
On the other hand, if you had the courage to grow the embryo to Day 5, and if it had arrested in the lab, you could tell her, "Look, the fact that it arrested in the lab means it would have arrested in the uterus, so you really haven't lost a chance at getting pregnant. This embryo was never destined to become a baby in the first place , and this is most probably because of a genetic defect in the embryo, which prevents it from growing further. More importantly, we've also obtained extremely valuable information . We now know for sure that the reason for your infertility is your poor egg quality. We've proven it to you , because your embryos has arrested in vitro. I know this is painful, but if you are willing to use donor eggs the next time, your chances of getting pregnant are going to be much better."  Now that she's seen for herself that her embryo has arrested in the lab, she's much more likely and willing, both emotionally and logically, to accept the option of donor eggs.
I think it's important that IVF doctors learn to take a holistic view of IVF treatment,  and not think of it only in terms of a single cycle. Yes, you could transfer the embryo on Day 2 and pat yourself on the back that you managed to reach the stage of embryo transfer. The patient is also happy with you , that at least you managed to create an embryo for her.  And when her cycle fails, you can make the diagnosis of "failed implantation"; make money by doing lots of very expensive ( and useless) tests; and then advice surrogacy !  Doing the transfer on Day 3 is a copout because it takes the pressure off you - but is not in the patient's best interests ! Some labs compromise by doing a sequential transfer - transferring some embryos on Day 3, and the some more on Day 5. This makes no logical sense at all, and just increases the risk of a multiple pregnancy.
On the other hand, if you have the courage to grow her embryos to Day 5,  and then it arrests  in the lab, she's going to blame you. You are going to have to give her a shoulder to cry on, and it's no fun having to console patients who are sobbing because their embryos have arrested. But in the long run, this is the right thing to do for the patient.
Finally, even though the numbers are very small, I believe this approach will improve pregnancy rates . We all know that the best place for a Day 3 embryo is not the uterus - it's the fallopian tube or the IVF lab. We were forced to transfer Day 3 embryos into the uterus in the past, because we were compelled to take a shortcut , since our laboratory technology was not good enough to grow embryos to Day 5 reliably . However, with today's advanced technology, when lab conditions are so much better , I don't think this is justified anymore. Just like a plant needs both a good seed as well as good soil, it's important to synchronise the embryo and endometrium when doing IVF - and the right stage for the embryo to reach the uterus is Day 5. A transfer earlier than this is a compromise, and not in the patients best nterests.
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 !

A free simple way of improving patient engagement

Patient engagement has become a buzzword today, and lots of efforts have been made to involve patients in their own health care.
Here's a free simple way which any doctor can use to empower their patients . After telling the patient what medicines he needs to take, he can request the patient to write his own prescription for himself.
After all, at the end of the consultation, the patient should know exactly what tablets they're taking; why; and when. If they can write this down, this reinforces the fact that they are right . This is a great form of teaching back, and reassures the doctor that he has done a good job of explaining the treatment to the patient.  Once the doctor has confirmed everything is correct, he can then sign off on the prescription , so that it's legally valid.
This approach creates a positive virtuous cycles. It checks that the patient has understood the information properly; and it audits the doctor's ability to communicate well. It will also dramatically improve patient compliance. After all, if the patient writes the name of his medicines himself, he is much more likely to remember what he needs to take, and when.  This simple act will reinforce his commitment to take the prescribed medicines. It will also ensure that the patient pays careful attention during the consultation, because he knows he is going to have to write down his own prescription !
When the doctor counterchecks the prescription,  he can correct any misunderstandings at this time, rather than wait for the patient to make an error because he did not understand the instructions properly . It also reduces the chances of the patient forgetting the instructions, because writing them down helps to strengthen recall. It will also ensure that the patient can read his own prescription , rather than trying to have to decipher the doctor's handwriting after going back home.
This is a simple and free technique. In case the doctor is very busy, the patient prescription can also be reviewed by the nurse. The patient can also write the instructions for each of the medicines in their own local language as well, so that the doctor doesn't need to worry about the patient's inability to understand English.
Writing their own prescription should be quite easy for a patient with a chronic illness, because they usually need to continue taking the same medicines. It will give patients a sense of power , because this signals that the doctor respects them, and expects them to know exactly what they need to do. It also makes it harder for the patient to conceal their ignorance - something which lots of patients often do, because they don't want the doctor to think they are dumb; or because they don't want to waste the doctor's precious time by asking "stupid questions".  When writing their own prescription, if they are not sure what they are taking and why, they will be forced to get their doubts clarified, and this will help to improve their care.
It will also help the doctor to become more empathetic, because he will be able to  understand and clear the patient's doubts. Doctors could also create a blank prescription template , and ask patients to fill this in, to make it easier for them. This can also help to save the doctor's time, because the patient is entering the names of the medicines himself.
Are there any downsides to doing this? These prescriptions are not valid until the doctor signs them, so I don't think there is any scope for misuse.