Tuesday, December 26, 2017

Why we specialise in treating patients who have failed IVF treatment

Most IVF clinics prefer treating patients who are coming to them for their first IVF cycle , because these are patients who have the highest chance of getting pregnant. Most clinics don't like treating patients who have failed an IVF cycle earlier, because the very fact that they failed in another clinic means that their chances of getting pregnant in their second cycle are lower as compared to someone who is doing their first IVF cycle, because they often have an underlying medical problem which is not easy to tackle.
However, we actually prefer treating patients who have failed an IVF cycle done in another clinic. For one thing , because they've been through a cycle before , they know exactly what's involved. They have realistic expectations of IVF treatment, because they've already dealt with failure . They have learned the hard way that the success rate in a single IVF cycle is never going to be 100%. They appreciate that all an IVF doctor can do is focus on the process and make sure that the treatment is carried out properly , because the final outcome is not in anyone's hands.
                                These patients are much more fun to treat because they're much better informed. They ask intelligent questions, and because they've done their homework, they keep us on our toes . This helps to improve the quality of care which we provide. They also provide us with a benchmark , because we can compare and contrast our practice with what they've done elsewhere .
Finally, most importantly, they can appreciate why we're better than most other clinics.               For patients who're doing the first IVF cycle with us, they can see we are good doctors, but they don't have any basis for comparison. On the other hand, someone who's done an IVF cycle somewhere else understands how much kinder and better we are. We don't make them wait unnecessarily; and we don't have any assistants, which means we're very hands on. We make all our decisions ourselves, and this allows us to customise the treatment protocol for each patient's specific problem. We're very open and transparent, and treat them as intelligent responsible adults. We are non-judgmental, and respect their personal desires and wishes, so they are empowered and in control.
We create a treatment plan for them, so they know what to expect; and we have created apps as well as tons of educational materials, so they can manage their IVF  cycle better. Finally, we routinely given them photos of their embryos, so they know exactly what's happening, and have peace of mind they have received the highest quality of care.
It's only when you have experienced the quality of care at an average IVF clinic that you can appreciate  how different and special we are !

 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 !

Sunday, December 24, 2017

How the leaders of the medical profession have let both doctors and patients down.

One would expect that the leaders of the Indian medical associations and the medical councils would serve as wise elders. They would stand up for doctors, and represent the public face of doctors to society. They would be the voice of the medical profession, so that they could ensure that the doctor-patient relationship was based on mutual respect and trust.

When society offers doctors the privilege of being professionals, they also give them the duty and obligation of self-regulation.  Doctors are meant to control and regulate each other, because they have access to specialized  medical knowledge which lay-people don't. Sadly, the medical associations and council have failed miserably at this task, and this is one of the reasons why patients don't trust doctors anymore.

Any time there is a case when the medical outcome is poor, the press is happy to bandy terms like alleged medical negligence or incompetence. These reports get blown out of proportion, and the media has a field day indulging in doctor bashing. These associations which should provide the doctor's balanced perspective, based on scientific best practices and evidence, unfortunately choose to keep quiet.

Ideally, they should have a Media Liaison , which offer s a 24/7 service, and connects journalists to experienced independent medical experts, who can provide a thoughtful unemotional viewpoint, based on medical facts. However, they maintain a studied silence, and let the doctor who is being accused of being a butcher bear the brunt of the media fire. Lay-people then mis-interpret this silence as being a tacit admission of guilt, as a result of which society gets to view a very distorted picture, where facts get twisted.

Sadly, most good doctors don't become leaders of these associations, because they don't want to get their hands dirty playing the petty politics which characterise the jockeying for power in these medical associations. They would rather be taking care of their patients , one on one , in their clinics and operation theaters. As a result of this, the  doctors who gravitate to becoming leaders of these associations are usually those who enjoy politicking. They often aren't doing well as clinicians, and are more interested in winning the elections for becoming the President of the association. They are focused on creating a vote bank for themselves within the members, and their primary aim is to earn a higher public profile for themselves, rather than looking after the profession's best interests.

Good doctors aren't very interested in power, which is why the leaders often end up becoming the ones who are more interested in furthering their own personal selfish interests . As a result of this, when something goes wrong in a hospital, the good doctors - the ones who have clout in the community because they're respected by their patients for their medical expertise - keep quiet , because they don't feel it's their place to speak up on behalf of someone else. And the medical association leaders - many of whom are often beholden to the government for their position of power - will not speak up , because they want to be politically correct and not ruffle any feathers.

What's even worse is that the few good courageous doctors who are willing to speak up on a public platform on behalf of their colleagues will get pulled down by these so-called leaders , because they are seen as being a threat to their positions of power. The association leaders will do their best to curb an independent voice, because they cannot manipulate it.

This is a huge tragedy, and we need individual doctors to speak up on behalf of all doctors everywhere ! Social media provides them with this platform, and doctors need to make use of it , so that they can explain to patients what they do and why !

Saturday, December 23, 2017

The sexless marriage as a cause of infertility

A surprisingly common reason for the inability to have a child in today's modern world is infrequent sex. Now, this may seem surprising in this day and age when you expect everyone to be so sexually aware. However, people living in large metropolises are so stressed out that they simply don't have time to have sex ! They spend three hours or four hours commuting everyday, so that by the time they come back home , they are dead tired.  Thanks to the mobile, they are always " on call", and have tons of work which they have brought from the office to complete, along with replying to emails and returning calls. You then just want to relax by watching a mindless TV serial , at the end of which all you want to do is go to sleep . It's hard to find the energy to be able to have sex, so you put it off to the weekend. And even if you are in the mood, your wife may not be, because she has her own tasks to complete . This is why a lot of modern couples end up having sex maybe just once a week - and sometimes not even then, because they have to complete all their weekly chores in their spare time, as a result of which finding the energy to have sex ends up taking a back seat.

                                Now, this is something they're not very proud of , and it's not information which they are willing to volunteer at the time of the first consultation with their doctor. They say, "Yes, we've been trying to have a baby for a year , but I'm still not pregnant, so I need medical assistance."  However, the reality is that they've just not had intercourse frequently enough to be able to get pregnant. This is tragic , because their infertility is not a result of a medical problem - it is social infertility - the price we pay for wanting to live in a city like Mumbai or Delhi , where the pressure is so much that perhaps the only relaxed time you get to spend with your wife is on a weekend. The husband's single-minded obsession with his work can become a sore issue , and the wife feels resentful and neglected, because he is not bothered about her desire to have a child.

                                Now, this doesn't mean that everything is gloom and doom. It just means that you need to set your priorities right , and find the right work-life balance . The truth is that your office won't go to pieces if you don't complete your work , but there's no one else who can get your wife pregnant - this is not something which you can outsource !

Here are some simple tips which you can follow in order to increase your chances of getting pregnant.

It's helpful to know what the fertile time is, and there are lots of free apps  such as MyFertilityDiary at www.myfertilitydiary.com which can help you time baby making sex, so you don't miss the crucial fertile days .

Lots of couples are surprisingly clueless about sexual anatomy and physiology, because they get their  "facts" from blue films ! Please buy a few good books on the basics of how to have sex, so you understand the basics. Classics like Alex Comfort's The Joy of Sex  are a great guide,

It might be a good idea to tell your wife to seduce you - this can spice up your sex life and make it more fun ! You should invest in some sexual toys , and watching soft porn together can help both of you get in the mood.

                                If you find that you're too tired to do it at night, then you might want to do it first thing in the morning , when you often have an early morning erection and can have a quickie. Using liquid paraffin to help with lubrication can also help to improve the chances of getting pregnant, because sex won't be painful for your wife, even if she is not aroused.

Hopefully, if you do a good job, you won't have to go to an infertility doctor at all - after all, it's much more fun making a baby in your bedroom !


Tuesday, December 19, 2017

Why do patients find it so hard to repeat an IVF cycle ?

Patients know that the success rate in a single IVF cycle is not 100% and they may require 3 - 4 cycles to get pregnant. However, lots of them drop out after one cycle , and are very reluctant to do a second . I sometimes wonder why this happens !
After all, an IVF cycle is a fairly straightforward treatment, which doesn't need hospitalisation or surgery, and requires only 4-5 visits to the clinic. In a good clinic, the treatment shouldn't be stressful at all.
However, unfortunately, the reality is that the way IVF is done in a lot of clinics does add a lot of unnecessary burden to the patient for multiple reasons.
Often there's a complete lack of transparency, which means patients don't have any idea what's going to happen on a particular day. Everything's done on a very ad hoc basis, so that they're completely clueless . They often have to spend hours in the clinic, waiting for someone to tell them what to do next. They have to put the rest of their life on hold, because they are stuck in suspense at the center all day long. Taking leave from work ; explaining to relatives why you're not being able to attend family functions; and having to make excuses to friends as to why you cannot party, because you are trying to hide the fact that you are doing IVF causes a lot of stress. The biggest tragedy is that this is completely unnecessary.
There's way too much waiting in most IVF clinics, because doctors perversely seem to take pride in having a waiting room which is overfull with patients.  This seems to stroke their ego, because it confirms who successful and important they are.
I can now see why patients are called patient ! They are to made to wait for scans; made to wait for the blood test results; made to wait to talk to the assistant doctor; and made to wait for the final instructions from the top doctor.
All of this is completely unnecessary in a well-run clinic. What's worse is that patients are made to come to the clinic every single day ! This makes no biological sense, because follicles grow at 1 2 mm per day, so doing frequent scans doesn't really change the treatment plan.  However, many doctors pride themselves on being very thorough and meticulous , and end up overmonitoring their patients, even though this does not improve IVF treatment outcome.  Ironically, patients are very impressed by how careful  the doctor is, because they don't understand any better !
To add insult to injury, some of the injections which doctors use (for example, the progesterone injections after transfer ) are oily and extremely painful . This is unnecessarily unkind, because we can administer the progesterone as a vaginal pessary, which is more effective and much easier ! Interestingly, it's only the US doctors who continue to inflict these painful shots on their patients - doctors in Europe are much kinder !
Lots of clinics overtest and overtreat their patients, using unproven injections such as low dose heparin  (  Clexane). These are expensive and unproven, but these aggressive doctors justify their use by citing anecdotal successes , and justifying these unnecessary prescriptions under the forgiving blanket designation of empirical therapy. These doctors enjoy overmedicating patients and giving them lots and lots of medicines, because they want to show that they are doing their best in order to get the patient pregnant. Patients naively continue to believe that more must be better. These include expensive medications such as growth hormone injections and intravenous immunoglobulins,  and patients are fooled, because they believe that the more expensive the medicine, the better it must be ! All these tests and treatments add to the burden of the patient - both physically and emotionally, as well as financially !
Now, patients know that IVF treatment is expensive, but they get sticker shock when they end up having to pay for all these unexpected add-ons , which no one tells them about in advance. The irony is that all this additional meddling is completely unnecessary - and rather than improve the patient's success rates, they just improve the clinic's profit margins !
Finally, there is the uncertainty of IVF which makes it so hard to deal with. Patients understand that the outcome is uncertain, but it can be hell living through the horrible two-week waiting period - especially when inconsiderate doctors force you to rest in bed for no rhyme or reason ! Each day of the dreaded 2ww can appear to be as long as a week - and it can be very hard to screw up your courage and be willing to subject yourself to that torture a second time.
What makes the process much worse is that most doctors refuse to share information with you. They don't even tell you basic stuff such as many follicles are growing; what your blood test results are and what they mean; how many eggs they collected; and what your embryo quality is. Sadly, the majority of clinics still refuse to provide embryo photos to their patients, and cut corners by not complying with global bets practices.
This is why patients often find themselves completely in the dark - even after the cycle is over. They end up wondering , "Even if I repeat the cycle, what would the doctor do differently the next time around ?" And when the doctor says, "I will do the following additional tests and treatments for you," the patient's unexpressed question is, "Then why didn't you do them the first time around?"
Their confidence in the doctor's medical competence gets shaken up when the cycle fails, which is why they're very reluctant to do another cycle.
This is a big tragedy, because we know that if patients are willing to be patient, their chances of getting pregnant in a second and third cycle remain extremely good.
It's time IVF doctors learned to be kinder to our patients !
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 !

Sunday, December 17, 2017

Taking the infertile man ( and his IVF doctor) for a ride !

All doctors know that a semen analysis has a number of limitations. While it can tell us how many sperm a man has, and how well they are swimming, they cannot answer they key question the infertile man is asking - Can I get my wife pregnant with my sperm or not ?

Now the right thing to do is to acknowledge the limitations of our sperm tests, and then move on with helping them to have a baby ! The beauty is that while the ability of our technology to test male infertility is poor, our technology for treating it is amazingly good, because we can bypass all the in vivo hurdles by doing IVF with ICSI. . This means  we can do in the lab what's not happening in the bedroom, no matter what the reason for the underlying problem !

Of course, doctors are never happy with accepting their ignorance, and like most people, they believe that more is better, which is why they have come up with a new set of sperm function tests, which are designed to test sperm function. Many of these have been proven to be useless ( such as the zona free sperm penetration assay ) , but scientists are always looking out for ways commercialise their reesearch.

The newest kid on the block is the Episona Advanced Sperm Quality Testing assay at https://www.episona.com/. The claim to use epigenetic testing to identify men who are at greater risk of having sperm dysfunction.  It's a cleverly designed website - but what it hides is the fact that it really does not provide any useful clinically actionable information ! Of course, this has never stopped andrologists for prescribing this expensive test, because they want to be seen as being at the "cutting edge" of research - even if this is completely useless as regards the patient's chances of having a baby.

The test report is full of genetic jargon, and describes how many fold the risk of having poorly functioning sperm is increased in a given man , based on proprietary tests the company does . They conveniently overlook the fact that the test results do not change the poor man's treatment options - but do live his wallet a lot lighter !

No wonder US healthcare costs are going through the roof !

The one things Americans are great at is marketing - and one of the reasons their healthcare costs are out of control is because they sell too many unnecessary medical tests and treatments !

A great example of this is the Foresight Carrier Screen marketed by Counsyl. US medical test manufacturers have realised that the trick to profitability is  not to limit their tests only to patients who actually need it, because this restricts the number of people the doctor can order it for . 

Instead , why not just get doctors to do the test for any couple who is planning to have a baby ? This way ,  their total addressable market becomes all the millions of couples who want to become parents, instead of just those select few who have a risk for having a genetic disease.

The marketing is slick - they sell to prospective parents, and prey on their anxieties; and in the litiginous US climate, it's very easy to get doctors to order tests - after all, they don't need to pay for these ! And it's temptingly easy to just tick off a check box on a fancy well-designed attractive form. The irony is that these tests are not needed  at all - which is why the results come back as normal for the vast majority ( as is to be expected for a screening test which is applied indiscriminately to a healthy population). Everyone is happy and reassured -  except for the poor patient who ends up footing an unnecessary bill, but has no idea what's going on, because everything is cloaked in esoteric genetic jargon !)

The latest "medical" study they are touting on their website to get more couples to push their doctors to order this test for them is being sold as a Landmark Study ! They know no one is going to bother to read the original JAMA article, where the conclusion was much more modest - " Conclusions and Relevance : In a population of diverse races and ethnicities, expanded carrier screening may increase the detection of carrier status for a variety of potentially serious genetic conditions compared with current recommendations from professional societies. Prospective studies comparing current standard-of-care carrier screening with expanded carrier screening in at-risk populations are warranted before expanded screening is adopted."

However, on their website, their marketing department has spun this as - The increased detection of affected pregnancies demonstrates the value of offering ECS to all patients, regardless of ethnicity !

Isn't  this deceptive advertising ?

The message to couples is also couched in very seductive terms  - The Counsyl Foresight Carrier Screen is a simple blood or saliva test that helps you learn your risk of passing down serious inherited conditions. Why would any couple refuse - after all, no one wants a child with a genetic  illness ! And it's so easy to say Yes when you doctor tells you that you need the test , because he has not bothered to applied his mind, and has got swayed by the clever marketing collaterals Counsyl produces.

You can read more about the harm this causes to patients at https://www.fastcompany.com/3059072/why-patients-are-getting-hit-with-surprise-bills-after-genetic-testing

Wednesday, December 13, 2017

The caring doctor

Patients often criticize doctors for being unemotional and distant . Because we are taught to maintain a professional barrier , we may seem to be cold and uncaring, but the reality is that doctors have a heart too - we're human after all !
Ironically, sometimes it's this humanness which backfires. Thus, we will often identify with some of our patients - especially when they're of the same age group, or come from a similar background. We sometimes need to break bad news to them , and when they start crying on hearing this, we get emotionally upset as well.  We may then end up saying things to try to console the patient, which he may then misinterpret . This can come back to haunt us , because the patient feels that the doctor was too frank and overstepped his professional boundary.
I recently had a patient who got pregnant after IVF , and I sent her to an ultrasound clinic for a viability scan at 6 weeks, to confirm her pregnancy was progressing well.  Her sonographer was worried that she couldn't see a beating heart, and told her - There is a possibility that this may not be a healthy pregnancy.  The patient broke down and came running to me in tears the same evening , saying - The radiologist told me my baby is dead !
Interestingly, the sonographer is an extremely good doctor who is normally very careful . Because she's a radiologist, she would never provide a clinical interpretation to a patient. Her standard answer is, "I have done the scan and my job is to report what I see on these ultrasound images . It's your doctor who's the clinician , and he will tell you what this means." Interpreting the image in a clinical context is the clinician's job, not the radiologist's, and good radiologist are acutely aware of this fact . So why did she bend the rules this time ?
She could see that the patient was very worried and agitated. The patient had read online that the inability to see a fetal heart at 6 weeks gestational age may mean that the pregnancy may not be healthy. She tried to calm the patient down by giving her some additional information , which the patient then misinterpreted, because she was so upset.
Yes, in one sense, the sonographer over-stepped her professional bounds , but she did that because she's a human being - a  good doctor who is empathetic and who cares for her patient.
I wish patients would appreciate how hard it is to be a good doctor ! It's hard to know where to draw the boundary between being compassionate and being detached. It's much easier being professional and maintaining a distance . We are warned by our professors that we need to be cold and objective if we want to practise properly, but we don't leave our hearts at home when we enter the clinic . When we try to be caring and connect with our patients, sometimes this backfires , as it did in this particular case.
I called up the doctor and told her what had happened. I needed to provide her with feedback , and I reassured her that what she'd done was in good faith, so she shouldn't feel bad about it. Her intentions were good , and her heart was in the right place, but sometimes even well meaning actions backfire. What she had said in order to alleviate the patient's anxieties and reassure her ended up causing the patient even more anxiety, because it's easy for emotional patients to misinterpret what a doctor means. When these messages get distorted, it causes a lot of harm to everyone.
I had to reassure her that it's often hard to draw a final conclusion so early in pregnancy, and that we need to wait and repeat the scan again in one week to check whether the pregnancy is healthy or not.
Patients forget how difficult it can be to be a doctor ! Handling patients who are crying in front of you can be tricky, because you want to be objective, but you also want to do your best to take their pain away - after all, this is why you chose to become a healer in the first place !

Friday, December 08, 2017

Why are IVF patients so reluctant to get a second opinion ?

If you are not happy with your IVF doctor, it's very logical that the next step should be to get a second opinion. However, most patients are extremely reluctant to do this .

For one, they have an existing relationship with their doctor , and they feel they will be disloyal and unfaithful to that doctor if they look for a second opinion - especially if they go behind his back ! (  Incidentally, this is not true. Every good doctor will encourage a second opinion because they want their patients to be happy with the care they are providing. They are confident that what they're doing is correct, and are quite pleased to allow another doctor to confirm this fact!) If your doctor doesn't want you to get a second opinion , or blocks you from doing this by refusing to give you your medical records, this in itself is a red flag !

Many patients are worried that the new doctor will make them undergo all the fertility tests all over again . Their experience has been that anytime they go to a new doctor, he badmouths the first doctor , and wants to repeat all the tests all over again,  because he doesn't trust the earlier laboratory. This consumes a lot of time; causes a lot of discomfort; and wastes a lot of money. This is why there is so much inertia, and patients usually prefer sticking to the known devil , rather than look for a new one. After all, what's the certainty that the new doctor will be any better ?

They are also secretly worried that if the new doctor points out that the quality of care their current doctor has offered is sub-par, this will confirm their worst fear - that they have wasted all their time, money and energy - and no one likes having their errors pointed out to them !

Ideally, if you want a second opinion, your doctor should be happy to give you a copy of all your medical records . In fact, he should be quite happy to reach out to the new doctor and help to facilitate the second opinion process , because he knows it's in everyone's best interests. Good doctors are professionals, and they understand that patients have the right to get a second opinion . They know that they are offering high quality treatment, and if the second doctor reinforces that fact, the patient will have even more confidence in them, and the trust will become even stronger.

Please explore the option of getting a second opinion - especially if you think your current IVF doctor is stuck and doesn't know what to do next !

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 !

Wednesday, December 06, 2017

How many IVF cycles should I do?

This is one of the commonest questions patients who have failed an IVF cycle ask when they come to me for a second opinion.
Is it worth doing another  IVF cycle?  What should I change ? Do I need to do anymore tests ? Should I expect to do three ? or four? How much stamina do I need? How much will this deplete my bank balance? Will multiple IVF cycles damage my health ?
Sometimes, with a lot of patients, you know that repeating the IVF treatment is futile, but many patients continue clutching at straws , because they're not willing to accept the truth.
Often they read about some fancy new research ( either in the newspaper or on a website )  which claims to dramatically improve IVF pregnancy rates . They some with this newspaper report or website printout, saying, "Can't you do this for me?" You then have to do through the details , and often you end up explaining to them that the research was done in a mouse laboratory, and has not been proven to be safe to use in humans,
Then they come after a few weeks , with a full page colour ad from a spanking new clinic that offers the "latest advanced technology" - and ask - Should I go to them, since they seem to offer much more than you can !
False hope can be cruel, but hope springs eternal in the breast , and if  it wasn't for hope, none of us would survive for too long. This is what makes things so difficult for both patient and doctor - it's no fund having to explain the limitations of modern technology to a patient who feels you have all the answers, and wants you to deliver a miracle.
A good doctor would tell the patient the truth that, "Look, a lot of these things which sound good on paper don't stand the test of time . New is not always better, and it's not a good idea to use yourself as a guinea pig."
However, patients need to make their decisions for themselves, and if they want to try something new, unproven and experimental, it's hard to stop them. After all, there is no medical risk when doing IVF - the risk is predominantly financial and emotional. If patients understand that and are still willing to go ahead, then perhaps a doctor should not stop them from doing what gives them peace of mind, even if this is illusory.
However, one thing which patients forget to factor in is the opportunity cost of doing repeated IVF cycles. After all, if you repeat the same thing, you're mostly going to end up with the same outcome - there's no logical reason for it to be different after you have done 4 IVF cycles .
The problem is that because you have locked yourself into repeated IVF cycles, you end up stopping yourself from enjoying all the other pleasures which life has to offer you. Also, this pig-headedness can stop you from exploring alternative options , such as adoption or third party reproduction - a decision which you may come to regret as you grow older.
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 !

Tuesday, December 05, 2017

How confusing sperm test reports end up confusing patients

A patient just sent me his sperm test report, and he was feeling very guilty that he had not been able to get his wife pregnant, because his report was so abnormal !

This is a great example of a bad report, because the doctor is providing a clinical opinion based on a lab report - something which a good pathologist will never do ! After all, interpreting the report and explaining it to the patient is the clinician's job !

Sadly, most gynecologists are completely clueless when it comes to making sense of a semen analysis report, and they also get confused with all the medical jargon this pathologist has stuffed his report with. All he has done is scare the poor patient !

He has also smartly suggested to the doctor that he should order additional expensive tests - which he is happy to do - at an additional charge, of course !

The fact that he says that normal counts can vary from 1 - 150 million means he is badly informed. However, because this is such an impressive report, both the referring doctor and the poor patient will get fooled.

Need help in making sense of your semen analysis report ? Read more at http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

Why PCO patients should induce a period every month

Polycystic ovarian disease ( PCOD) is a common cause of infertility. Typically, most of these patients have irregular cycles because they don't ovulate regularly. Now, because they don't ovulate, they don't get pregnant , and they don't get regular periods either . This is because they produce a lot of estrogen, but there's no progesterone production at all, because of the lack of ovulation.

Now, this means that every time they miss a period, they're very hopeful that this time they could be pregnant. They wait and they wait, and after two months or three months they don't get a period, they finally go to a doctor who does a pregnancy test and then induces a period for them with tablets which contain progesterone. This happens once; then it happens twice ; and when it happens again and again , they start getting fed up and frustrated.

A lot of them are very scared of all these hormonal tablets which their doctor uses to induce a period , because they have been told that artificial hormones are dangerous ! They are worried that they will cause cancer; or will have side effects ; or that they'll get dependent on these tablets , which means their body will never start working properly. As it is they have low self-esteem, and this just makes it worse.  A lot of them believe that if these tablets are powerful enough to induce a period, then if they accidentally take the tablet when they are pregnant , they will end up miscarrying and losing the pregnancy.

This is why they waste a lot of time waiting to get a period. Not only does this false hope just add to their stress, it is also the cause of a lot of wasted opportunities. Until they induce their next period, they're not going to be able to ovulate,  and therefore won't be able to get pregnant. This means that if in an entire year, if they only get a period four or five times, their chances of getting pregnant on their own goes down dramatically.

This is why PCO patients must induce a period once a month , so that they have a better chance of getting pregnant Once they've induced a period, they can then try to induce ovulation in the next cycle. The tablets which  are used to induce a withdrawal bleed contain a hormone with the unpronounceable name , medroxyprogesterone acetate ( MPA for short).

The good news is that these tablets are  extremely safe. These are natural hormones, the same hormones their body would normally have produced if they'd ovulated on their own . Because it's a natural hormone, it has no long-term side effects . Of course, the tablets only act in the month in which they take them . This often confuses them, because they feel that they have become "dependent" on the tablets.  The truth is that the underlying disease remains - after all, the progesterone doesn't treat or cure the PCOD - it  just induces a period , and that is it's only role.

The beauty about progesterone is that it's very safe during pregnancy. This means that even if they take it inadvertently when they're pregnant, there is absolutely no risk to the baby. 

Taking progesterone to induce a monthly period is something which PCO patients need to learn to do for themselves - and a good doctor will teach them how to do this, so they don't have to go running to the doctor every month every time they miss a period. Patients need to learn more about their chronic disease , so they're empowered enough to be able to manage it for themselves. There are a lot of simple things that they can do for themselves, so they don't have to seek medical attention unnecessarily , or waste a lot of time in their quest to have a baby.

Even if PCO patients don't want a baby,  they should still induce a period every month. Otherwise, the continuous unopposed estrogen exposure will cause their uterine lining to build up, and endometrial hyperplasia can be a premalignant condition if not treated properly.

You can read more about how we treat PCOD at

Friday, December 01, 2017

Poor quality IVF treatment

I received this tearful email from a patient.

I have a very sad medical history .  I used to get extremely painful periods (I got my first periods at the age of around 14-15 years) where medical help was always required by me. The doctors in my home town could not understand the problem and we were completely relying on the best doctors of our city. I was treated for depression, epilepsy, abdominal TB, hormones, etc. etc. because they believed that my symptoms were similar to any of these ailments.
After years of treatment but no relief (around 11 years of treatment with no solid diagnosis, no reports nothing), I got married at the age of 28 and there after when I was not able to conceive my husband took me to SCI International Hospital in February 2016. After proper diagnosis they told us that I was suffering from endometriosis. I had my laparoscopic and hysteroscopic surgery in October 2016 at Indraprastha Apollo Delhi. I got my next periods in around Feb-Mar 2017 after surgery.
Thereafter it was followed by two IUI failures and two IVF failures. My last negative HCG report I received on 28th November 2017. My doctor says everthing was good. She said it was magical that I had good number of eggs during both my IVF cycles, with two Grade A and one grade B each time. So everytime they put in three embies in me and everytime it did not exist.
The doctor says probably it is not God's will otherwise they had tried their best. I am not much satisfied by blaming God and myself. If everything was good then why did I have so many failures. There must be some reason behind it? The reason is yet undiscovered. If the problem is with eggs then why did I get grade A embryos each time and if the problem is with uterus then even donor eggs cannot help me...
I strongly believe that if there is a problem, there will be a solution to it. The only thing is 'a right person who can given right suggestion is required'. I request you to kindly go through the reports that I am attaching with this mail and provide your valuable suggestions.
I replied, asking for more details about her IVF cycle, so I could offer suggestions. After all, I need more medical details, so I could guide her properly.

Can you send me more details about your IVF cycles ?
You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos
What were the  meds which were used for
superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood at the time of the HCG trigger ? What was the endometrial thickness ?
How many embryos were transferred ?
What was the embryo quality ? 
Can you please send me the printed treatment summary from your IVF clinic ?
Her reply was

Thanks for your kind response. I do not have any photos of my embryos. Should I ask my doctor to share it with me? I mean I was not aware that photos of embryos are also taken during the treatment but if it is taken during the procedure, please confirm, I will then speak to my doctor about this. 

This is a patient with a complex problem, whose IVF doctor has not been transparent and open with her.  Anyone who says the embryos were Grade A , without specifying the number of cells in the embryo and giving embryo photos , is not being completely honest. Of course, part of the problem was she didn't know what questions to ask, as a result of which her doctor did not bother to share the basic details with her.

If she had done her homework before starting her IVF cycle, she would have learned that the only tangible product an IVF clinic can deliver is embryos , and all good clinics provide embryo photos proactively and routinely to all their patients, to document they have delivered high quality medical care.

Sadly, she has learned the hard way that she can't leave everything upto the doctor either - and she needs to be a well-informed patient, if she wants to get the best medical care !

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 pregnancy rates are better with single Day 5 embryo ( blastocyst) transfers

Logically, one would expect that the pregnancy rate would be better if we transferred two embryos at a time, as compared to putting back only  one .  Yes, this is true if you calculate the success rate per transfer, but not true when you calculate the cumulative pregnancy rate - the total chances of getting pregnant after transferring all the embryos back.

Let's assume you have 2 top quality blastocysts, and that each blastocyst has has a 30% chance of implanting if we transfer it in an optimally receptive endometrium.

Now if we put two embryos back at the same time, each of them has that 30% chance,  and the limiting factor will be endometrial receptivity. If the endometrium is optimal, then there is high possibility that both may implant, which is why the twin pregnancy rate is high after IVF.  Sadly, our technology for assessing endometrial receptivity is still crude, and we are forced to depend upon the endometrial thickness and texture as measured on the ultrasound scan to judge this , because the new generation ERA ( Endometrial Receptivity Assay ) tests are a waste of time and money.

Now the reason why only one implants ( and the other doesn't, even though the uterine lining is receptive) is because one of the blastocysts has a genetic problem ( which we cannot test even with PGS, because PGS only allows us to count the number of chromosomes) , and this prevents it from implanting. This is why transferring two blastocysts has a better pregnancy rate than transferring just one  when you calculate the success rate per cycle - you are improving the chances of transferring a genetically normal embryo by putting back two instead of one.

On the other hand, it's possible that when we transfer two genetically normal blastocysts,  neither of them will implant because there's a problem with endometrial receptivity. This means no matter how many blastocysts we transfer in that cycle , none of them would implant. If we put two together , we have wasted both these precious embryos . On the other hand , if we put one at a time, each embryo has its own chance of becoming a baby, because the endometrial receptivity may be better in one cycle as compared to another. This way, we are maximizing the probability of achieving a pregnancy for these women , because we are making the best possible use of these blastocysts.  I agree this sounds very hit and miss, but sadly these are the current limitations of IVF technology today, and ERA and PGS do not help in overcoming these.

The truth is that each blastocyst is worth its weight in gold , and should be given the best possible chance of becoming a baby. The best way of doing this is by transferring one single blastocyst at a time in an optimally prepared endometrium. Yes, this does have disadvantages , because it does mean that the patient needs to come back again for the next cycle, in case the first one fails.

However, the good thing about transferring frozen embryos after thawing them is that this is a simple procedure , which is not expensive. The patient doesn't need to take any injections and it can be done in a natural cycle as well.  Because we can focus on optimizing both the embryo as well as the endometrium , because we're doing these independently, the overall chance of achieving a pregnancy is much better. Sometimes, less is more !

Rather than just calculate pregnancy rate per transfer, patients need to focus on the cumulative conception rate, so that their chances of taking a healthy baby home is maximized.

Is your doctor suggesting you transfer more than one embryo in one cycle ? This suggests he has no confidence in his IVF lab, and you should look for another IVF clinic !

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 !

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