Dr Anjali Malpani has been honoured with the Times Healthcare Achiever Award 2018 in Mumbai

The IVF hurdle race !

The IVF lab is the heart of IVF treatment, where we keep the eggs and sperms safely and allow the embryos to grow until they form good quality blastocyst, which are ready to either be frozen or to be transferred into the uterus. Now, the most important thing an IVF lab does, is make sure there are no toxic elements within the culture medium, within the laboratory which could damage the embryo growth.

But the fact of the matter is that there is very little we can do to actually facilitate or accelerate or enhance embryo growth. After all, the growth of the embryo depends on the energy which is provided by the egg itself, and there is very little which we can do in order to enhance or improve this. And this is one of the short comings which an IVF lab has. That we have to work with whatever biological raw materials we have available. This is why IVF success rates for older women are lower than those for younger women. And it can be frustrating when embryos don't grow well in a good quality laboratory, but if you're sure that the quality of the lab is good, then this is something we just have to learn how to live with. 

And how can you check the quality of the IVF lab ? By asking for photos of your embryos ! You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Certifying the quality of an IVF lab

Patients know that there is a lot of variability between the success rates of IVF clinics, and they are not sure how to make sure that they one they select is a good clinic or not.

Should they go by their family doctor's advice ? or the size of the advertisement the clinic pays for in the newspaper ?  How reliable is word of mouth ?

I wish there was a Hallmark for IVF clinics, which patients could use to ensure that they are taking treatment at a high quality clinic. Sadly, the Indian government has done a poor job with regulating IVF clinics, which means any one can call themselves an IVF specialist,  even if their pregnancy rates are abysmal.

The good news is that there is a simple technique well-informed patients can use to protect themselves - insist that your IVF clinics give you photos of your embryos !

Good IVF clinics do this proactively and routinely, so you don't even need to ask. And if your IVF clinic does not follow this practice, then this is a red flag, and you should look for another.

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Sperm DNA fragmentation does not affect your fertility !

A patient just send me this email

I have had a sperm test done and my Sperm DNA Fragmentation ( DFI) index count is 40 %. My doctor says my wife will require a sperm donor. 

This is a classic example of how over-testing leads to poor medical care and harms patients.

Doctors don't understand the limitations of the newer medical tests, and are quite happy to order the "latest and most expensive " tests when treating their patients - especially when they have no idea what's going on ! They cloak their ignorance with the garb of sophisticated scientific test results - and the poor patient gets misled !

The reality is that there is no correlation between  sperm DFI and male fertility. Lots of fertile men will have  a high sperm DFI , but they have enough sense not to go to a doctor to get it tested ! There's too much overlap in the sperm DFI results in fertile men and infertile men to make the test meaningful or useful.

However, doctors don't understand that these tests are riddled with the problem of false positives, and are very happy to "treat" the abnormal test result ( because they forget that they should be treating the patients, and not the lab report !)

So what role does sperm DFI testing have to play ? It should be used very selectively, only for couples who plan to do IVF. Studies should that if a couple needs IVF, if the man has a high sperm DFI, they should opt for ICSI rather than IVF , because the fertilisation rate with IVF is lower as compared to ICSI in these men, that's all !

The only way to protect yourself from clueless doctors is by investing in Information Therapy !

You can read more about sperm DNA fragmentation tests at 

https://www.drmalpani.com/about-us/press/sperm-dna-fragmentation-assessment and 

http://blog.drmalpani.com/2011/07/is-it-egg-or-sperm.html

Is there any connection between Grade C embryos and the risk of birth defects ?

A patient asked me this question.

Can Grade A embryos result in abnormalities in the baby ? Or do only Grade C results in abnormalities ? 

Sadly, there is still a lot of misunderstanding  about embryo grading . Most embryologists are not skilled enough to be able to grade embryos properly, and because many IVF specialists have never set foot in the lab , they don't really understand what embryo grades mean. And if the IVF doctor is so confused, it's hardly surprising that patients are completely in the dark.

Embryo grades are basically lab shorthand for describing the appearance of the embryo - how it looks under the microscope . There is no correlation between birth defects and the grade of the embryo . Top quality embryos have a better chance of implanting and becoming a baby , but even if a poor quality embryo does implant, the risk of that baby having a birth defect is not increased !

This is why IVF patients should insist that the IVF clinic give them photos of their embryos, so they understand on what basis the grading is being done . Sadly, most IVF lab don't bother to provide photos, and their grading is very arbitrary, because they can say what they like, and they know they can get away with this !

Thus, they tell the patient - we have transferred 3 Grade A embryos for you - without even telling the patient how many cells the embryo had ! The poor patient is forced to trust the doctor, because they don't know any better - and it's too late to do much about this now, because you've already paid your fees !

All good IVF clinics provide photos to all their patients routinely and proactively, because it helps to increase the trust their patients have in them.

Being able to see your embryo photos allows you to compare them with an atlas of embryos, so you can check the grading for yourself - and no, you don't need to become an embryologist to do this ! This transparency will your upgrade be without even providing basic information as to how many self the embryo hearts and just missed you a lot of confusion and misunderstanding for the poor patient.

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

The limits of IVF technology

The IVF lab is the heart of IVF treatment. We keep your eggs and sperms safely in the incubator, and your embryos grow in the IVF culture medium in vitro, until they form good quality blastocysts, which are ready to either be frozen , or to be transferred into your uterus.

The most important thing an IVF lab does is make sure there are no toxic elements within the culture medium or the laboratory , as these could damage the growth of your embryos. We want to keep them happy, so they thrive in vitro, until they are ready to go back into your uterus !

However, sadly there is very little we can do to actually enhance the growth of your embryos. This is because the growth of the embryo depends on the energy provided by the mitochondria in the cytoplasm of the egg, and there is nothing we can do as yet to improve this.

This is one of the limitations an IVF lab has to live with - we have to work with whatever raw materials we get. After all, IVF is an ART - an assisted reproductive technology, where we given nature a helping hand. Yes, it can be frustrating when embryos don't grow well in a good quality laboratory, but if you're sure that the embryologist is an experienced expert, then this is something you have to learn to accept.

This is why it's so important to make sure your IVF lab gives you photos of your embryos - so you can make sure they have been nurtured with tender loving care in the lab !
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 !

World's first infertility Chatbot !

We have created the world's first infertility chatbot, to help infertile patients learn more about their problem.
Naima is an intelligent digital medical assistant, who will help you find what you need to know !

Check her out at www.ivfindia.com

This is a beta release, and your feedback will help us enormously in improving how she answers your   queries ! Please be kind - this is a work in progress

The difference between IVF outputs and IVF outcomes - what every patient needs to know !

What every patient ( and every doctor) wants from every IVF cycle is a happy ending -  a baby. It's great when we can achieve this happy outcome, but sadly IVF does not have a 100% pregnancy rate, which means many IVF cycles fail.
While this is heartbreaking, the patient then needs to plan what to do next, and this is why it's so important to differentiate between output and outcome.
The output is the end-result of the IVF treatment , and this is something which a doctor can control. This is tangible, in the form of top quality blastocysts.
However, once we transfer the blastocyst back into the uterus, we have no control over whether this will implant or not, which means we cannot predict what the final outcome ( a baby) will be.
Patients need to check the quality of the IVF treatment they receive based on the output - the embryo quality - rather than the outcome.
This is why it's so important to ask for photos of your embryos.
All good clinics provide these routinely and proactively
You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

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

How can we make IVF more affordable in India ?

I often see lots of infertile patients who could get pregnant if they did IVF treatment. Unfortunately, they just cannot afford to do an IVF cycle for financial reasons, and they end up without a baby. It fair to say  that  this causes them a significant amount of  frustration and heartburn when you know that IVF can help you get pregnant; but you can’t, because you just can’t afford the treatment.

Can this be changed?  

But it’s not just the patients who are affected; IVF specialists also go through a lot of anguish when this happens. It’s very difficult to come to terms with the fact that   though there is a medical solution, you are unable to offer it to a patient, simply because she can’t afford it. This isn’t the case only in India, but across the world, there are people who have to forgo IVF because of the cost factor. So what can be done to make the treatment more affordable?

In India, it would make a big difference if the government accepted the fact that family planning and welfare does not just mean limiting family size, but also helping couples to achieve their desired family size. If government hospitals & medical colleges began offering IVF programs, they would easily be able to afford to this in a cost-effective manner.

Our medical colleges are churning out a large number of M.D. gynecologists who haven’t really had any exposure to IVF treatment; it’s a shame that these gynecologists are under qualified. If IVF is offered at these hospitals, both the purposes would be served. Infertile patients would get quality care, and there would be an entire generation of gynecologists who are being trained properly!

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Read more- How Expensive are Fertility Treatments - Test Tube Baby Cost in India

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Insurance companies say “no” to IVF

Health insurance companies don’t cover IVF treatment. The excuse they give is that infertility isn’t a medical disease and that it’s no more than a lifestyle illness which doesn’t make it eligible to be covered under insurance. Patients don’t have the means to fight back and the companies get away with it.

The simple solution is that infertile patients should form an NGO which would establish that infertility is a medical problem and that it should be covered by insurance just as any other medical treatment would be.  This would make the treatment much more affordable for a number of couples.

So, why is IVF so expensive?

One of the main reasons is because doctors inflate their charges by saying that their years of training, the expensive IVF equipment, the disposables etc, make it very expensive. This is true to a certain extend; however, if they use economies of scale, they will be able to provide more affordable IVF treatment to patients.

 If they start treating a larger number of patients and use innovative technology (like vitrification for freezing), it will improve their success rates and inexpensive IVF treatment can be much more than a pipe dream.

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Read more- Store your Embryos using Vitrification

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

Why didn't this blastocyst implant ?

The truthful answer is - We don't know !

This doesn't mean we are stupid or ignorant - it just means medical technology has its limitations, and we need to learn to live with them, by having realistic expectations of what IVF treatment can accomplish - and what it can't !

So what do we know ?

We know that human reproduction is not a very efficient process, and that most embryos will not implant because they have genetic abnormalities we still cannot test for. This is the limitation of IVF technology today, and we need to come to terms with it.

The problem is that patients are unhappy when the doctor tells them the truth, because they want the comfort of certainty. Sadly, this is a mirage, but in order to keep patients happy and placate them, doctors will spin all kinds of tales to explain away the failure. Usually this involves "blaming" the patient , and this victim-blaming comes in all kinds of flavours
- you did not rest enough
-  you were too stressed out
- you did not take your medicines on time
your egg quality was poor
- your husband's sperm were bad

Doctors cook up all kinds of fanciful pretexts, but this false pretense just causes more harm. They end up subjecting the poor patient to all kinds of useless tests and treatments, which just waste money, but don't improve success rates !

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 !

What do we need to change for our next IVF cycle

After her IVF cycle failed, a patient sent me this email

In retrospect what do you think could have gone wrong? Is there anything I need to improve or change ? 

It's important to learn from each IVF cycle by analysing what went, and what didn't. The right time to do this is at the time of embryo transfer, because it is only until this point that we have any control. We can only three tangible variables -

embryo quality

endometrial ( receptivity) thickness and texture

the ease of the transfer

Once the embryos have been transferred into the uterus, we have no ability to check what happens inside the uterus. All we know is that human reproduction is not a very efficient process, and that most embryos will not implant because they have genetic abnormalities we still cannot test for. This is the limitation of IVF technology today, and we need to come to terms with it.

This was my answer to her.

No, there's no need to change anything, since it was a perfect cycle ( top quality blastocyst, excellent endometrium, easy transfer)

The problem is that human reproduction is not perfect !

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 !

IVF failure - incompetence ? or bad luck ?

IVF failure can be the result of bad luck , or sometimes the result of the IVF doctor's incompetence . The key question the patient wants an answer to is - How do I differentiate between the two ? 

Did my cycle fail in spite of the fact that the doctor did everything right " Or did it fail because the doctor wasn't able to make good embryos in the lab ?

The only way to answer this question is by getting photos of your embryos , and doing enough homework so you are able to interpret the images of your embryos . The good news is that this is easy to do - and if you need help, please feel free to email me !

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

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

How to prevent errors in IVF - what every patient needs to know !

The biggest nightmare for any IVF patient is that the lab may mix up their eggs and sperms with another patients. This has happened in many clinics, and IVF is as prone to errors as any other treatment because it is provided by a host of people working together – doctors, nurses, receptionist, ultrasonographers, lab technicians and embryologists. It requires lots of coordination, and there are few treatment processes for which a team approach is more important than for assisted reproduction. Close, continuous communication is required at many levels to ensure everything goes as planned.

Communication matters

All of these can produce an environment of controlled chaos that must be managed. Important to the issues of patient safety and the integrity of an ART program are the ways in which a program handles the difficult issue of medical errors. Total freedom from error is only possible in theory. Response to errors, when they occur, reveals the integrity of the program and should be based on established processes.

The errors

* One, in which the eggs or sperm are mistakenly used with the gametes of another person; or the wrong embryo is transferred to a patient

* The second, which leads to the loss of sperm, eggs, or embryos (for example, because of a power failure as a result of which the incubator malfunctions).

IVF mix-ups are every patient’s and doctor’s nightmare, and lots of high profile cases have been described where this has happened. The trouble is that eggs, sperms, and embryos look exactly the same under the microscope ! Errors can be avoided by:

* Obsessive labeling

* Double witnessing, where a second person double checks the identity of all the dishes in the lab can help reduce this risk

* Electronic witnessing, using coding and RFID (radio frequency identification) technology has also been introduced to prevent gamete mix-ups.

If a mix-up does occur and is noticed, this must be brought to the doctor’s attention immediately. Even if the embryo has not been transferred, the patient should be informed, so they can decide on a course of action they are comfortable with.

The second type of error may or may not lead to a reduced chance of reproduction. A loss of part of a sperm specimen or improper handling of immature oocytes may not result in a dramatic change in the outcome of the cycle for the patient. Although there can be a difference of opinion about whether this should be disclosed, the ASRM Ethics committee states that it’s best to disclose even minor mistakes that have potentially adverse effects for patients. “If, on the other hand, there is clearly no adverse effect and if disclosure may unnecessarily compound the stress of patients, disclosure may not be obligatory.” However, the perception of dishonesty resulting from attempts to cover errors is often worse than the actual medical error.

Maintaining transparency is important

Process mapping

In addition to reducing effort, which in turn can decrease the sources of error, the process map gives all the staff members an overview of the complete treatment cycle, so that the right hand finally knows what the left hand is doing. This improves coordination and communication, and allows each staff member to put patients first. Because they can see the big picture, the staff is now no longer just focused on doing their individual job, but understands that their goal is to help the patient along her IVF journey.

Flow process diagrams allow us to assess the risk of error at each step in a clinical process. For example, what would happen if the lab did not report the estradiol value in a timely fashion to the doctor when he is timing the HCG trigger shot? The systematic evaluation of risk points can lead to an action plan that results in minimal errors in the future.

Establishing metrics and tracking provides a means for following the success of error reduction over time. Parameters can be as simple as checking to see what percentage of patients are phoned the day after egg collection to make sure they are comfortable and are not developing OHSS. Such simple proactive measures can help to make IVF safer for patients.

We use an EMR (electronic medical record) to document that we have provided treatment correctly and safely. This allows team members to communicate with each other, and with the patient as well.

The laboratory is the last stop in the complex process of IVF treatment and laboratory personnel must confirm that all consents are current and complete for the intended treatments. In the absence of these documents (whether paper or electronic), the embryology laboratory should not perform the procedures.

Improving safety is not the responsibility of only the clinic staff. Thus, drug manufacturers have started to provide the medications which patients need to self-inject daily in pre-filled syringes, so that their chances of making a mistake in taking the injections is reduced. The patient is the final line of defense against errors. Making sure the patient knows what is supposed to happen next is the best way of reducing errors. This is why we have created the free My Fertility Diary app (www.myfertilitydiary.com); it allows patients to track and monitor the progress of their IVF cycle. If they know what’s going on, they are empowered to speak up when the cycle does not progress as planned.

Regular interaction is required to assure that infertile couples are adequately prepared, and that scans, blood tests, egg collections and embryo transfers are performed seamlessly. IVF offers a wide variety of mix-and-match treatment options, because there can be multiple sources of eggs, sperms, and uteri; and lots of different physicians are involved, including reproductive endocrinologists, urologists, anesthetists and counselors.

IVF programs can be madhouses of activity, and the possibility of an error creeping in is every IVF clinic’s nightmare. There are two primary types of errors in IVF:

Good IVF clinics have policies and procedures in place that deal specifically with medical error. These should include definitions; statements about who should be informed, when, and how; and mechanisms for determining the cause of the error and preventing its repetition. Policies should encourage a culture of openness, address the ill effects of trying to cover up errors, and very importantly, include corrective actions to minimize future errors. They should be based on the understanding that errors can and will occur, and that a better assessment of errors will improve the mechanisms for preventing and correcting them. This has a positive effect on staff morale, which further enhances safety. A mechanism for reporting both within the clinic and the laboratory allows for analysis of near misses. Incidents that do not result in harm should also be reported to allow process optimization that can prevent serious errors.

IVF care is a complex clinical process, and the clinical activity needs to be categorized into compartments. This allows us to depict them as flow diagrams that allow study of sources of error or risk. This promotes the ability to streamline the interaction of multiple complex tasks performed by different clinical and administrative units such as nursing, laboratory, and billing departments.

IVF for treating recurrent miscarriages

Recurrent pregnancy loss ( repeated miscarriages or habitual abortions) is one of the most frustrating problems in medicine. It is hard for patients , because getting pregnant , and then losing the baby again and again is traumatic. It's bad for doctors, because patients have so many questions , and we don't have any answers ! The truth is that our tests are not very good, and there is little we can do to make n accurate a diagnosis. This is why, in about 80% of patients with recurrent pregnancy loss , inspite of extensive testing, we will not be able to find an underlying cause.

Based on experience over many years, the one thing we do know is that the commonest reason for a miscarriage is a genetic problem in the embryo.                What makes this so tricky is that these are random genetic errors which we cannot pinpoint; cannot test for; and cannot prevent. This is why pregnancy becomes such a hit and miss affair for these patients. It's literally a gamble, and there are patients who have had three and four miscarriages , who have then gone on to have a healthy baby with no intervention other than TLC - tender, loving care !

So what is the poor patient to do? She can, of course, keep on trying in her own bedroom but, obviously, every time she loses her baby, her heart breaks.

One option is to do IVF. Now, logically , this seems to make no sense at all !  Patients say, " Isn't IVF a treatment for infertile couples ? Since  I'm getting pregnant in my own bedroom, this means I am fertile, so why would IVF help me ?"

The reason is because it saves these patients precious time. In a fertile woman , off the eggs which she produces every month, in 11 of the 12 months this egg is healthy and genetically normal, so that if it forms an embryo and implants , she goes on to have a healthy pregnancy. However, even in these women, 10% of the time the egg will be genetically abnormal , and give rise to a genetically abnormal embryo, which will miscarry. This is why about  10% of all pregnancies miscarry , even in fertile women, and there is nothing much we can do about it.

Now, it's possible that for women with recurrent pregnancy loss the rate , at which they produce genetically abnormal eggs is higher than it is for normal women. Let's assume that 80% of the eggs which they ovulate are genetically abnormal, which means these will form genetically abnormal embryos, which then have a much higher chance of miscarrying.

There is nothing much we can do about this when she is trying in her bedroom, but if we did IVF , we would get lots of eggs in that one cycle. We could create lots of embryos, and allow these embryos to grow to day five ( blastocysts) , which means that a lot of the genetically abnormal embryos would not develop up to this stage. By transferring only top-quality blastocysts , we'd reduce the risk of a genetically abnormal embryo implanting, because the chances of the blastocyst coming from a genetically normal egg are that much higher.  So why not test the embryos by doing PGS before transferring them. Sadly, this  has not been shown to be helpful , because the PGS technology is still very immature, and only allows us to count the number of chromosomes in the embryos.  Yes, the holy grail is to improve the genetic technology to screen for all abnormalities, but  until we reach that point I think this is a perfectly acceptable option for trying to improve the odds of a woman with recurrent pregnancy loss having a healthy baby more quickly rather than allowing nature to take its own. Yes, she may still miscarry even after doing IVF, but the chances will be lesser, so this is an option she may want to pursue.

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 !

Second opinions for IVF patients

While second opinions can be quite helpful in reducing " avoidable medical care" , they come with their own set of challenges. . Patients are scared about seeking out a second opinion because they are worried that by doing so, the doctor who is treating them will get offended and may disengage himself from the treatment. Patients are scared of physicians and don't want to risk antagonizing them!

The two sides of the coin

1. Not all second opinions are correct. Sometimes, it's the "first opinion" which might have been the right decision for the patient, and only time is able to tell which doctor was right. It's naive to simply assume that the second opinion was better than the first! Let's not forget that doctors who give second opinion are also often biased to giving one which is different from the first opinion – after all, doctors love playing a game of one-upmanship to show they are better than their colleagues! Second opinion services are incentivized to "adding value" to patients by providing a different perspective. Not surprisingly, a third opinion could be completely different!

2. Second opinions can aggravate the situation. It might be convenient to take a second opinion online, but this may end up leaving the patient confused and paralyzed into inactivity when the opinions differ. Who does he believe? The online anonymous doctor who has been positioned as being an expert? Or his personal doctor, who knows him and whom he can talk to face-to-face? Conflicting opinions may also cause him to lose trust in the medical profession in general, and in his doctor in particular. This erosion of trust is harmful for the patient, because if one cannot trust his/her doctor, it's harder for healing to take place.

3. The true value of a second opinion is realized not when it differs from the first opinion but rather when it agrees with it. This reassures the patient that he is on the right track, and it reinforces his confidence in his doctor.

Empowering the patient
There are few black and white areas in medicine. Considering there are multiple options available to both doctors and patients, the whole activity of seeking a second opinion should not degenerate into a doctor vs doctor game, driven by individual egos.
It's important to emphasize the key role the patient needs to adopt in making the final decision. It's not enough to just take a second opinion, and then leave the final decision to a doctor. A mature patient acknowledges that it's his responsibility to make the final call! The mantra in medicine today is “shared decision making,” and patients need to become expert, empowered, and engaged so that their voice is heard.
That doesn’t mean patients need to become medical experts! However, they do need to learn to use information therapy, which aids patients in making the right decision . Information Therapy provides patients with evidence-based guidelines, so that they can ask for the right medical treatment they need – no more and no less.

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

How many IVF cycles will it take for me to get pregnant ?

There are some questions which IVF doctors cannot answer accurately, and one of these is the commonest questions patients ask - How many IVF cycles will it take for me to get pregnant?

Patients know that IVF doesn't have a 100% pregnancy rate and that they need to be patient. They are prepared to repeat the cycles, and this is a perfectly valid question to ask , because this helps them to prepare mentally and financially for a journey which can be taxing and stressful.

However, the frustrating reality is doctors can't answer this simple query accurately for the individual patient. Yes , we can provide group statistics and offer cumulative conception rates for a group of patients. Thus, we know that if 100 patients do 3 IVF cycles, then 80% of them will get pregnant, we don't know what the individual patient's chances are.

Now patients don't really care what happens to the other patients in the clinic - they only want to know what their own chances are. This is a variable which depends on multiple factors, including their age, their egg equality, their endometrial receptivity and other biological intangibles we still can't measure.

This is why when we counsel patients,  we tell them what the average success rates in our clinic are, but we tell them that we can provide a much more precise estimate of what their specific chances are only after we have done their first IVF cycle, and can assess their embryo quality properly.

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

Why a picture is worth a 1000 words in an IVF cycle !

This is why patients should always insist that their IVF clinic provide them with photos of their embryos. This helps to keep the IVF clinic honest !

Good clinics provide embryo photos routinely and proactively, because they are transparent, open and accountable. 

Sadly, not all clinics do this as yet - and this is why patients should be assertive. 

The best time is before you start your IVF cycle and have paid your charges - otherwise you will be fobbed off with all kinds of lame excuses . The worst one I have heard is a complete lie - " We don't take photos because this will damage the embryos !"

The truth is that bad clinics don't have the courage and confidence to give embryo photos to their 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 !

Root cause analysis for IVF failure

 We treat lots of engineers and computer programmers who are infertile , and when their IVF cycle fails, they ask us, "Can we please do a root cause analysis to find out why the cycle failed?"

After all, they are engineers and think logically and analytically. They want definitive answers , and are upset when we can't provide these. Root cause analysis works extremely well when you're dealing with inanimate objects, but unfortunately, what applies to machines cannot be extrapolated to human beings.

This doesn't mean that doctors are illogical or lazy - it just means that our technology has limitations, and we can't always answer a patient's questions because there are too many complex variables and moving parts in an IVF cycle.

When we explain this to patients , they're not very happy , because they expect their doctor is an expert who will be able to provide answers. The reality is medical science has constraints, and we can't track the fate of an embryo after we transfer it into the uterus.

This is why  it's hard to pinpoint what the causative factor for an individual patient's IVF failure are . Biological variables changes all the time, because this is a complex adaptive system, and providing simplistic answers just to pacify the patient does not help anyone.

There's no point in doing unnecessary tests and unnecessary treatments simply in order to pander to a patient's query. It's much better to be upfront and honest with the patient and say, " Sorry, there are some questions we can't answer yet. However, just because we can't identify the exact problem is not a cause for worry. We are very good at finding solutions bypassing problems , even if we don't know what they are precisely". This can be very reassuring for patients - after all, an IVF clinic is not a research enterprise - our goal is to give our patients a baby, and this is something we are very good at !

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 !

Overdiagnosis in IVF - how some IVF clinics increase work for themselves.

Lots of IVF doctors are very trigger happy, and make a diagnosis which is completely inaccurate. For example, they will do an ultrasound scan for a patient on the fifth or sixth day of the cycle and notice at that time that the follicles are small or the endometrium is thin , and then tell her, "Oh, your thin endometrium means that you most probably have endometrial tuberculosis, and you need investigation and treatment for this." 

This is plainly ridiculous ! On Day 6, most fertile women will have small follicles , because they haven't started growing yet , as a result of which their estrogen levels are going to be low, which means their endometrium is bound to be thin. This is normal , and doesn't mean there'a anything wrong. If they repeat the scan in another 4 days, they will see that the follicle grows and the lining will become thicker. 

However, the moment the doctor starts creating this doubt and suspicion in the patient's mind, they generate a lot of unnecessary anxiety, and I think it's important that doctors stop doing this.

The trouble is that they take advantage of the fact that patients are not very well educated or well informed . Most don't understand what the doctor is saying, and quite frankly, infertile patients are so desperate that they will pretty much accept whatever a doctor says, especially when the doctor is an IVF expert. 

This ploy allows doctors to create a lot of busy work for themselves, because once you've made a " diagnosis" , you then need to confirm it . This means you subject the patient to even more tests, which would include things like hysteroscopies  or endometrial biopsies, which not only waste a lot of money, they also waste a lot of time .

This is why the doctor needs to be systematic  and well organized, and not be opportunistic and do a test whenever they feel like. There is a standard protocol which needs to be followed for all patients, and tests should not be done just because the patient happens to come for a consultation on Day 6 of her cycle ! 

The only way to prevent this kind of abuse is to make sure that patients are well informed.

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