Saturday, April 27, 2019

What should we change in the next IVF cycle ?


A patient sent me this email

Dear Doctor, 

As you know, my first cycle failed, even though everything was perfect, and I am heartbroken !

You have suggested that we stick to the same medical protocol , but I have a bunch of questions which I would like you to  answer .


1. Should we opt for PGS or test the endometrium health to assess the exact issue?

PGS reduces pregnancy rates in my opinion. Read more at http://blog.drmalpani.com/2015/05/how-pgs-overpromises-and-underperforms.html

The ERA test is also a waste of money ( but very profitable for doctors to do !)


2. Can the timing of the embryo transfer be an issue? I usually used to ovulate around day 12 during the IUIs, isnt the endometrium receptivity the best at this point? We transferred at day 15 during this cycle, looking to understand how does this work exactly for my own mental satisfaction?

We don't transfer according to the calendar date, but according to the time when endometrial receptivity is optimal

3. Could/should I opt for alternative medicines like acupuncture or a detox program like panchakarma? Should I go on to a specific diet program? 

There is no harm in exploring these options, but we don't have any medical evidence that they improve pregnancy rates

5. Should we be screening for any auto immune disorders which could be a possible reason for failure ?


 6. If we do nothing different will the result not be exactly the same?

No - it's just that it takes time to make a baby, and you need to be patient !
If a fertile couple doesn't get pregnant after trying actively for 6 months, this does not mean they can't get pregnant in the 7th month !

7. What are the success rates for first time IVF?

30% per cycle  when we transfer a single blastocyst - remember that human reproduction is not an efficient enterprise , and it takes time to make babies in the bedroom as well!

I understand your heartache and frustration. There is a lot of pressure on the doctor to do something
 " new" or "different" - but newer is not always better ! Embryo implantation is an inefficient biological process, and we need to live with its limitations. 

Please don't expect instant gratification and please have realistic expectations !


What to find an IVF clinic which respects your time and intelligence ?





Friday, April 26, 2019

Why biology is no longer destiny for Indian women.



Once upon a time, career women who were ambitious had to make a hard choice when they were 30 . They knew that their fertility was maximal when they were young, and that the best time to have a baby was when they were about 25. On the other hand, this was the time when they were growing rapidly in their career, and if they wanted to get promoted, they couldn't afford to take a break in order to have a baby. This was a major dilemma, and they were unsure what to do.

Today, fortunately, young Indian professionals have a choice , which allows them to eat their cake and have it too ! They can freeze their eggs when they are 30 , which means they can safely postpone childbearing without worrying about the impact pursuing a career will have on their fertility. After they've reached whatever level they want in their career and are ready to have a baby - which means they could be about 40 at that time - they could use the eggs which they froze when they were 30 to be able to have a healthy baby.

Women need to use this medical option so they can retain control of their life , without sacrificing anything.


Thursday, April 25, 2019

Why professional women should consider freezing their eggs routinely when they are 30



Everyone knows that egg quality declines as women get older, and their chances of getting pregnant drop. This is why women who want to pursue a career are in a quandary. Should they defer child bearing, because they want to become the CEO? Or should they get pregnant, put their career on hold, and then maybe pursue a career later on after their children have grown up?

 Many Indian women  are aware of the fact that egg freezing allows them to have their cake and eat it too, because they can freeze their eggs when they're young , without taking a break in their career, and use these frozen eggs to have a healthy baby once they've reached their professional goals
Because this option is so valuable in empowering women to exercise  their reproductive options, progressive companies like Google and Facebook are happy to offer egg freezing free for their employees, so they can retain them.

Tragically, Indian women aren't still doing this routinely, even though egg freezing is so much cheaper in India. I think this is partly because they overestimate the success rate with IVF, and don't realize that the chances of getting pregnant with IVF when you're 40 years old are poor.

This ignorance proves to be expensive, and they often end up kicking themselves for not being more proactive when they were younger !



Wednesday, April 24, 2019

Why aren't young Indian professional women freezing their eggs?



We often see women who are now 40 and want to do IVF to get pregnant. They postponed having a baby because they were busy pursuing their career, and are dismayed to find out that the chances of having a baby with IVF at their ager are low, because their egg quality has dropped dramatically as they have aged.
They wish they had got pregnant when they were younger, but the tragedy is that we  can't reverse the clock.
When I tell them that they could have frozen their eggs when they were 30, they are very upset that their gynecologist did not discuss this option with them at that time. They missed the chance to have their cake and eat it  too, because egg freezing would have allowed them to continue pursuing their career safely, and use their 30 year young eggs when they became 40, and were ready  to have a baby.
Many of these older women why their younger colleagues , who in their 30s,  aren't aware of this option that they should be freezing their eggs if they want to protect their reproductive potential.
This is partly because there are still lots of misconceptions about egg freezing and IVF success rates, and need to be dispelled, so women don't kick themselves later when they get older and find that they are now infertile because their eggs have aged.


Wednesday, April 10, 2019

When you should worry about the quality of your IVF clinic !


If the embryologist doesn't even bother to spell "single" correctly, you should worry a lot about his competence and ability !

Monday, April 08, 2019

Allowing IVF patients to decide


 As an IVF doctor, I'm very respectful of patients' preferences. After all, infertility is not a medical problem, it's a social construct. Lots of people are quite happy not having a baby, so if they choose not to have one, that's their choice too ! We treat them as intelligent adults and explain all their options to them, including adoption or third-party reproduction, so they can make a well-informed choice.

I try not to be dictatorial, which means if they have personal, we encourage patients to express them, and try to work with them.

On the other hand, I'm still the doctor in the room , and as a medical professional, I will not perform medical interventions which will reduce their chance of getting pregnant, even though it is profitable for me to do them.

Thus, doing lots of tests can help me generate a lot of money , but this is not in their best interests, as it does improve pregnancy rates. There is a whole list of procedures which many other IVF clinics do to maximise their profits, but we will refuse to do these. These include: ERA testing; PGT; immune therapy; NK cell testing; TB PCR testing; empiric therapy with LMWH ! In fact, the fact that there are so many "empiric" treatment options clearly means that nothing works !

Some patients appreciate the fact that we are being conservative because we are good doctors, and put their interests first. They are happy to work with us,  because we explain to them why we are not doing these unnecessary tests and treatments. However, others are extremely unhappy , because they think this means we are technologically backward, and they go on to find a doctor who's more willing to do what they demand !


What to find an IVF clinic which respects your time and intelligence ?









Saturday, April 06, 2019

Being Infertile does not mean that you are a failure !




One of the problems of being infertile is that patients start thinking of themselves as failures, since they can't even do such a simple thing like making a baby in their bedroom - something which millions of women do routinely all the time.
This can be very hard to come to terms with, especially for a lot of young, successful, professional career women , who are so used to getting everything they want in life.
They are academically smart, accomplished , do well in exams, get the job which they want, and the husband they want.
When they find that they can't get a baby, their self-esteem takes a big hit, and they start wondering whether they're good for anything else at all.
This can be extremely difficult because in one sense this  is the first time in their life they're coming to terms with their own biological frailty - their own mortality in one sense.
The fact that not everything is in their control can be very unsettling. Some become bitter and angry, while others acquire a certain degree of humility . They are able to cope better , because they understand that they should be grateful for what they have , and learn to make the most of this.

What to find an IVF clinic which respects your time and intelligence ?







Friday, April 05, 2019

How much does an IVF cycle cost ?



IVF can be an expensive treatment, and cost is a major constraint for lots of patients, who need to be careful about how they spend their money.
The problem is that lots of IVF clinics provide very misleading information about how much they charge for an IVF cycle. Many take out full-page ads , saying they charge only Rs 25000 for an IVF cycle, which seems like a very attractive bargain for infertile couples.
However, it's only when the patient starts the cycle, that she realizes that there're all kinds of additional costs she has to pay for , which were hidden from her. However, once she's started the treatment, she forced to cough up, and can't back out !
These include things like the cost of injections; the cost of additional procedures , such as hysteroscopy; or the " facility fee". Unfortunately doctors can be very creative about adding costs when they're doing IVF , and this can come back to hurt the patient.
This is why you must insist on an all inclusive cost - preferably a package price, so there are no hidden expenses , and no surprises. Otherwise, the additional expense can come as a rude shock to patients, especially when they're locked in for a three cycle package, and then the doctor keeps on adding charges for additional tests and treatments.
What patients really want to know is - What is my total cost for taking a baby home ? The cost per baby is the right question to ask !
Thus, even if the clinic is cheap, but their pregnancy rate is poor, you will end up wasting a lot of time and money, with no results at all !

What to find an IVF clinic which respects your time and intelligence ?






If you only have one embryo, should you do a Day 3 or a Day 5 transfer ?

Thursday, April 04, 2019

SYSTEMATIC INVESTMENT PLAN (SIP) STRATEGY IN IVF

Why transferring one embryo at a time is the best option for IVF patients !



Patients are often confused as to how many embryos to transfer, especially when they have three or four top quality blastocysts. Many of them want the doctor to put back more embryos, in order to maximize their chance of getting pregnant in the first cycle itself.
This may be tempting, and while it is true that putting two embryos back will increase the chances as compared to transferring just one in that single cycle, this comparison can be very misleading.
Thus , putting back more than two embryos, especially when these are top-quality blastocysts, is a bad idea because of the risk of high-order multiples or triplets, which can cause a lot of problems for the babies, and is not advisable.
Even when compare one vs two, you should be measuring a "cumulative pregnancy rate," and not just the rate for one cycle.  If you put two embryos back in one cycle, and you don't get pregnant, then you've lost both, and will have to start a new fresh cycle, which is expensive. On the other hand, if you put one at a time, even if the first cycle fails, you still have the second frozen embryos as a backup, and transferring frozen embryos is much less expensive !
This is why patients should think about cumulative pregnancy rates over multiple cycles, as compared to the pregnancy rate in only a single cycle !

What to find an IVF clinic which respects your time and intelligence ?






The IVF doctor's dilemma

Wednesday, April 03, 2019

Why the IVF lab is a lot like a kitchen

Allowing IVF patients to make their own decisions



As an IVF doctor, I'm very respectful of patients' preferences. After all, infertility is not a medical problem, it's a social construct. Lots of people are quite happy not having a baby, so if they choose not to have one, that's their choice too ! We treat them as intelligent adults and explain all their options to them, including adoption or third-party reproduction, so they can make a well-informed choice.

I try not to be dictatorial, which means if they have personal, we encourage patients to express them, and try to work with them.
On the other hand, I'm still the doctor in the room , and as a medical professional, I will not perform medical interventions which will reduce their chance of getting pregnant, even though it is profitable for me to do them.

Thus, doing lots of tests can help me generate a lot of money , but this is not in their best interests, as it does improve pregnancy rates. There is a whole list of procedures which many other IVF clinics do to maximise their profits, but we will refuse to do these. These include: ERA testing; PGT; immune therapy; NK cell testing; TB PCR testing; empiric therapy with LMWH ! In fact, the fact that there are so many "empiric" treatment options clearly means that nothing works !

Some patients appreciate the fact that we are being conservative because we are good doctors, and put their interests first. They are happy to work with us,  because we explain to them why we are not doing these unnecessary tests and treatments. However, others are extremely unhappy , because they think this means we are technologically backward, and they go on to find a doctor who's more willing to do what they demand !

What to find an IVF clinic which respects your time and intelligence ?







Busy IVF clinics vs efficient IVF clinics!

Monday, April 01, 2019

How many IVF cycles should I try?



Patients know that the pregnancy rate in a single IVF cycle is not 100% , and that they need to be patient until they get pregnant.
A key question is - How many cycles should I try?
After all, they need to know how much time and energy they need to devote to IVF, and how much this is going to cost them.
This is always a tricky question, and the answer is - It depends !

There are many variables at play here !
What are your goals ? To experience pregnancy, or to have a baby ?
What are your personal preferences ? Will you consider using donor gametes ?
How old are you ?
How much money can you afford to spend ? How important is this for you ?

From a medical perspective, each IVF cycle will give us valuable information, so we can answer this question more accurately, rather than just provide a generic answer which is imprecise.

Remember, an IVF cycle is not just a treatment cycle ! It gives us valuable diagnostic information as to why you're not getting pregnant in your bedroom ( because it allows us to check egg quality and the ability of the sperm to fertilise the egg).

Equally importantly, it provides us with invaluable prognostic information which we cannot get using any other technique.  Thus, if we get top quality blastocysts, we can advice you that it makes sense to repeat the cycle again. If we don't, then you may be better of considering alternatives, such as donor eggs, to maximize your chance of achieving a pregnancy.

What to find an IVF clinic which respects your time and intelligence ?






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