Dr.Malpani's Blog

Teaching patients how to ask good questions

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 14 Feb 2012 03:16:00 +0000

I encourage patients to ask questions. This is important, because it allows them to understand exactly what their problem is ; and what their treatment options are , so they have realistic expectations as to what I can do for them.

However, sometimes patients ask such poor quality questions that it's very hard to provide intelligent answers. This is why doctors sometimes get so frustrated by patients who carry lists of over 100 questions , and expect the doctor to answer all of them. The truth is that the quality of the doctor’s answers depend on the quality of the patient's questions. The problem is that patients are not sophisticated enough to be able to differentiate between good-quality questions and bad quality questions.

How can doctors help patients to ask good quality questions ?

This needs to be a two-step process. Firstly , patients should compile a list of generic questions and then try to answer these questions by doing their homework online. If they do this properly about 80 percent of their questions will already be answered before they go and see their doctor . This way, the doctor can focus on the really important stuff , which applies to their individual problem . Doctors can encourage this by providing information to patients on their own website , so that most of the generic questions have been answered before the actual consultation starts. This will save the doctor a lot of time and also ensure that the answers to the generic questions are retained by the patient, because they've been clearly documented. Many studies have shown that patients forget about 50 percent of what their doctor tells them during the consultation , so that this kind of blended approach helps to ensure retention of information by the patient.

Patients need to learn what questions to ask ; and how to ask them. This is an important skill, which is worth acquiring , and doctors can play an important role in teaching patients the difference between good quality questions and poor quality questions. Broadly, if the question can be answered by doing a google search, it’s not a good idea to ask this question to your Doctor . Good-quality questions are those which relate to your specific problem ; and which require the doctor to tailor the information specifically to your condition .

This approach will create a win-win situation , where patients get satisfactory answers to all their questions ; and doctors are happy because they've been asked intelligent questions , and their time has not been wasted on generic stuff.

Yes, I agree we also need to teach doctors how to provide good quality answers to good quality questions – and this will be the subject of another post!

Using Felopio and herbs to unblock your fallopian tubes naturally

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 13 Feb 2012 03:06:00 +0000

Every once in a while I come across a website which make my blood boil, because it takes advantage of an infertile women's ignorance; and exploits her hopes and desires to make a quick buck.

A good example is www.felopio.com, which promises a " natural herbal remedy " which will allow women to open their blocked tubes.

This is a very tall claim to make - but they can make it and get away with it, because it's a herbal remedy, so it does not need to be tested or approved ! Also, this is the internet, so people can make any claim they want !

Felopio is a tampon which contains herbs , which are supposed to work their magic on the fallopian tubes, after being placed in the vagina. This is a very clever marketing ploy, and even though it's all hocus-pocus, it's not hard to understand why it's so successful.

Women would rather try natural stuff at home rather than go to a doctor - and if they can order a simple remedy sitting at home, they are very tempted to do so ! Using felopio is easy to do - and because they can do it for themselves, they feel they are taking control of their problem and tackling it proactively.

Husbands also like the idea that this is a DIY remedy , which is safe and non-invasive. After all, what's the harm of trying it out ? It's local - and putting the herbs so close to the tubes makes a lot of intuitive sense ! So what if doctors don't recommend this ? Doctors don't know everything, do they ? Aren't there lots of other herbal remedies which have been shown to be effective
( which doctors don't learn anything about ?) Even if doesn't work, at least it won't do any harm ?

It's true that it's tempting to buy this product. The site is very attractively laid out - and is full of glowing testimonials and (unauthenticated) success stories.

Yes, it's true that some women may get pregnant after using Felopio - but this does not mean that the Felopio opened their tubes ! Often, the diagnosis of "blocked tubes" itself was wrong in the first place. It's common for doctors to report the tube is blocked, when actually it's just a cornual spasm which prevents the dye from entering the ( open) tubes.

The tragedy is that it is still very easy to fool infertile patients, who are deperately seeking a quick fix solution. It's easy to prey on their ignorance - and this results in their wasting valuable time and money .

Don't get taken for a ride - your best protection is Information Therapy !

i am 9 days late and and 3 pregnancy tests have come out negative. What could be wrong ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 11 Feb 2012 03:17:00 +0000

As we all know, the commonest reason for missing a period is pregnancy. This is why, when you miss your period, your first thought is - Am I pregnant ? If you are infertile and have been trying to conceive for some time, there's a lot of hope and suspense when your period does not come on time.

So you check by doing a urine pregnancy test - and keep your fingers crossed - hopefully, this is the time when you've finally hit the jackpot ! Maybe it's the weekend trip you took which finally did the trick ?

However, when you find the test is negative, your hope go crashing to pieces ! Maybe I did the test too early ? Or perhaps I didn't do it right ? Aren't there lots of stories of women who were pregnant but whose pregnancy tests were negative for many weeks ? Maybe the test is not very reliable ?

The reality is that urine pregnancy tests are quite reliable - and if these are negative, this most probably means that you are not pregnant.

Your next step is to do a blood test for HCG to find out if you are pregnant. This is much more reliable. If this is negative, this establishes the fact that you are not pregnant.

This means the reason you missed your periods is because you did not ovulate. This is called anovulation. You may need to induce a period with medicines.

Why I no longer want to practise medicine

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 10 Feb 2012 15:03:00 +0000

I recently met a classmate of mine who been practicing as an obstetrician and gynecologist in the city of Bombay. He was a bright student and had his own nursing home ; and had what I thought was quite a flourishing practice in the suburbs. However, when I met him , he told me he was planning to retire from medicine altogether. I was quite surprised , but what he told me opened my eyes . This is what he had to say.

I have been practicing as a doctor for the last 25 years , and I am proud of the fact that I provide good medical care . I enjoy taking care of my patients - and my patients love me . It's been very satisfying , but so many things have changed now , that it's just not worth the hassle to continue practicing medicine as an independent doctor in private practice in my 15-bed nursing home anymore.

For one thing , the rules and regulations have become so onerous and difficult that I seem to be spending half my life just filling up forms and doing paperwork - for renewing my registration for my nursing home ; for the insurance paperwork for the TPAs; and complying with the biomedical waste rules. I'm at the mercy of any bureaucrat or clerk who wants to come and trouble me , and there's very little I can do about it.

I used to do ultrasound scans , but now I have stopped doing them. Every time I do an ultrasound scan , because of the PNDT Act, I have to fill up the form which says I have not disclosed the sex of the fetus. Why can't people just accept the fact that doctors are respectable citizens ; and that it's not good for our self-respect to be treated as crooks and criminals .

I no longer have the autonomy which I used to have . A lot of my patients have insurance ; and filling up their paperwork ; getting pre-authorisation; and following up with the insurance companies for my payments has become such a pain , that I no longer have the energy to do it .

Finally, I don't think my patients respect me as much as they used to. They no longer treat me as a trusted a professional. They think I am mercenary ; and often challenge my recommendations . Medicine is no longer considered to be a very respectable profession , and I'm pretty much fed up , which is why I want to retire. It's because we have not stood up for each other that doctors like us have contributed to this decline - we only have ourselves to blame !

What will you do in that case ? You are only 50 !

That's not a problem at all . I own my own nursing home ; and given the astronomical real estate rates in Bombay today , I will get a huge amount of money by selling it . Even if I just park this in a fixed deposit , the interest I get will actually earn me much more than what I'm getting from my medical fees right now ! I'll be quite happy and contented - and don't forget I'm a Doctor , which means I am smart. I'm sure I'll find something to do without having to deal with all the daily hassles I have to put up with today.

It is a shame and tragedy that things have come to this pass. We don't realize how much harm we do by pushing doctors against the wall . Some of this damage has already happened in the US , where primary care physicians no longer want to take on new patients , because they are fed up of the restrictions which are being placed on them. Sadly , the Indian medical system seems to have imported all the bad bits and bobs of the West; and sooner or later , we're all going to pay the price. Most doctors no longer want their children to become doctors anymore , so that the profession which used to attract the best and the brightest is no longer seen as being desirable . This is one of the reasons why we have all these private medical colleges which charge huge tuition fees - and we are now producing a new generation of doctors, which is more focused on the bottom line rather than being focused on providing good patient care. I dread the day when I become older and fall ill !

When things go wrong in the IVF lab

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 10 Feb 2012 03:00:00 +0000

The IVF lab is the heart of the IVF clinic . This is where we nurture your eggs and sperms to make your embryos ; and grow these embryos carefully before putting them back in your uterus , to maximize their chances of becoming a baby. In most well-run IVF labs , things go as expected , because we are very scrupulous about making sure that proper procedure is followed ! Biological systems usually behave themselves and do what they're supposed to do, provided the IVF lab has the right equipment and the right expertise.

However , it's also true that sometimes things do go wrong. When something bad happens in an IVF lab , we first need to a document the problem. It's important to identify what happened; and then to troubleshoot to try to figure out what went wrong and why.

Unfortunately , many IVF clinics will try to hide the fact that something bad has happened. They will often not share this information with the patient and try to cover it up . This causes harm both to the patient and to the IVF clinic, because they fail to learn from their errors.

There is a long list of things which can go wrong in an IVF lab . For example , eggs may fail to fertilize after IVF ; the eggs may get damaged after ICSI; the embryos may fail to divide in vitro ; they may not divide as fast as expected; the culture medium can get infected as a result of which the embryos may die ; sometimes samples get lost or mixed up ; or samples get mixed up with another patient’s , because of labeling errors or clerical problems .

It’s important to be aware of all the possible things which can go wrong , so we can institute safeguards and processes to prevent these mistakes from occurring. If a mistake does occur
( this happens very rarely in well-run labs ), it’s important to document this ; to report it to seniors ; and then try to figure out what went wrong ; and what we can do in order to fix the problem. It's important to level with patients and tell them exactly what happened ; and provide a possible explanation is to why it could have happened.

Sometimes the honest truth is we don't know why bad things happen. For example , you may do five IVF treatments on one day , and out of these five patients , four will do well and for some unexplained reason , the fifth one doesn't . Sometimes hard to pinpoint what the problem is. This is just one of those facts of life and with increasing experience and expertise it becomes possible to troubleshoot and identify problems more accurately. It's important that these be carefully documented - preferably with photographs ; and shared with patients, so that they know exactly what happened . More importantly, we can help them try to figure out what to do differently the next time around , in order to increase their chances of having a baby in their next cycle, even if we can't fix the problem in this particular cycle. It can be hard to tell patients the truth when something goes wrong, but it’s far better to be honest and upfront. Patients may get upset, but they will appreciate the fact that you told them the truth.

Why do patients come to India for IVF treatment ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 09 Feb 2012 16:37:00 +0000

This website has an excellent study on " Trans-national Reproduction: An exploratory study of UK residents who travel abroad for fertility treatment".

It is estimated that over 40 million women worldwide are currently seeking fertility treatment. There are indications that, for a variety of reasons, individuals and couples from many developed countries are increasingly travelling outside their home states in their quest for a child. Although there has been a high level of media interest in those who seek to use the services of overseas fertility treatment providers, and much speculation about the causes and consequences of this practice, so far there has been little systematic research in this area. This project was designed to fill that gap. ‘Transrep’ was a qualitative research study, designed to explore the experiences of people who are involved in the process of cross-border reproductive care, either as a ‘user’ of services, or as a ‘provider’ of services.

The study sought to answer the following questions:

Why are people travelling abroad for fertility treatment?
What are the possible personal and social implications of overseas treatment?
How can treatment providers, regulators and patient groups support couples who are faced with decisions about travelling overseas for treatment?

Judgment based medicine versus evidence based medicine

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 09 Feb 2012 14:00:00 +0000

Modern medicine is based on scientific principles . This can be very reassuring for patients , because they know that doctors have a body of evidence which they can trust ; and use logical principles in order to treat them correctly. However, medicine is not an exact science. It's an uncertain science , and this is hardly surprising given the fact that we're applying this science to a complex biological system - the human animal.

Doctors are used to dealing with this kind of biological variability because they spend so many years in medical school ,learning that they can be a lot of variation between the way patients respond treatment. However, when it comes to insurance company bureaucrats , policy wonks, and hospital administrators , this kind of complexity makes them extremely uncomfortable . They are much more comfortable handling numbers , which are much more predictable ! This is why they would rather deal with cut and dried systems , which make logical sense on paper. This explains why protocols and flowcharts and algorithms and guidelines have become so popular . Doctors today are being pushed into practicing medicine using published guidelines, rather than their own personal judgment or clinical intuition . This is why the movement towards evidence-based medicine has become so popular.

If you have a rigid yardstick to measure doctors by, it's easy for clerks and pencil-pushers to see whether doctors are performing according to that yardstick ! Those who do can be incentivized to continue doing so; whereas those who don't can be appropriately penalized . Evidence-based medicine has been thrust upon doctors and patients , not because it's better, but because it easier for non-doctors to manage, because it's less messy than real life medicine ! It's has been dressed up as providing patient centered care while it's really system centered care.

The difference between the two is highlighted very well by Doctor Groopman in his book, Your Medical Mind . He criticises the modern fashionable trend towards evidence-based medicine , where all patients are treated like widgets. We cannot afford to continue to pretend that one-size-fits-all ; and that if the guidelines are followed, all patients will behave exactly the same way . Since Doctor Groopman is a practicing physician who deals with the uncertainty and orneriness of real life medicine daily. He feels that doctors should be allowed to apply their judgment , so that they can tailor evidence-based medicine to an individual patient, and practice what he calls judgment-based medicine.

This is what you should ask for the next time you visit your doctor !

How to Have a Baby - the Comic Book for Infertile Couples

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 09 Feb 2012 04:22:00 +0000

How to Have a Baby - the Comic Book for Infertile Couples

Are you unhappy with your IVF Doctor ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 09 Feb 2012 03:09:00 +0000

I often see patients who complain bitterly about their IVF doctors , saying that they just didn't have the time to talk to them ; or that they never explained anything to them . When I go into their history , I find that they've done three cycles with the same Doctor ! This is something which I just can't understand . If you do one cycle and you're not happy with your doctor, then why would anyone in their right mind repeat the second and third cycle with that same doctor ?

When patients are unhappy with their IVF doctor , why do they continue going to him ? Lots of patients are happy with their IVF doctors because most IVF doctors are competent , proficient and empathetic – and they do their best to help their patients to have a baby. However, it's true that some are pretty bad ! They are either incompetent; or not very communicative or open about what they are doing and what's happening during the IVF treatment.

While patients can't do much about how their doctor chooses to behave, it is within their control to decide whether to go back to that doctor when the first cycle fails ; or to change doctors . Why do patients continue going back , even if they not very happy with their
doctor ? Some patients feel trapped - they don't know that they can explore alternative options ! Others feel the known devil is better than the unknown one – after all, what’s the certainty the new doctor will be any better ? The fear is that they may be going from the frying pan to the fire and that the new doctor may be even worse than the old one. At least this one knows my case and my details and has all my records ! Others are scared to leave because they don't have their medical records ; and are worried that if they go to a new doctor , they’ll have to repeat all the tests and spend all that money all over again.

Some of them fall prey to the sunk cost fallacy - we’ve already invested so much money and energy and time with this particular doctor , that it’s better if we continue sticking with him. Others have been taught that they need to be faithful to their doctor. They understand that it takes time to get pregnant after IVF and that it's better to stick to the same doctor even if he's not very good and if they not very happy with him, rather than to switch doctors.

One way of getting out of this hopeless situation is by encouraging patients to get a second opinion . This is something I think every patient should routinely do when the first IVF cycle fails , so they have a clear understanding of whether they are on the right track or whether there are other options they should be exploring . If the second opinion doctor offers a perspective which is different from the first , this means they now have additional options to explore . They can always go back and discuss these options with the first doctor - or maybe even switch to a new doctor , if that's what they prefer .

Getting a second opinion helps you in many ways ! The new doctor is likely to treat you with kid gloves and be on his best behavior , because he knows you're already taking treatment from another IVF doctor and are a potential new patient . He’ll treat you like a VIP and do his best to make sure you come to him. Even better , when your original doctor finds out that you gone to another doctor to get a second opinion will be much more careful when he answers your questions , because he knows that you may walk away and that's not something which he wants !

It is not always easy to get a second opinion, and we try to make this easier for patients by offering a free second opinion online. This is an option which costs you nothing and it's well worth exploring because at least it helps you find out whether you're on the right track or whether you should be looking for alternatives . And because we’ve made this so painless, you don’t even need to switch doctors if you like your present doctor !

Why do patients make the wrong decision sometimes ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 08 Feb 2012 12:58:00 +0000

Patients are often forced to choose between various alternatives when they are ill . They sometimes make the wrong decision. Doctor Groopman's book , Your Medical Mind , provides some very interesting insights into this phenomenon. Making a decision involves thinking, as as with any other thought process, we are exposed to the risk of four common cognitive biases when we make medical decisions.

The commonest cognitive bias is called framing. It's very easy to be influenced by the promotional literature which a pharmaceutical company provides ; and by the glowing testimonials on a medical website , when you need to make a decision for yourself . Our decision making process is commonly flawed , because of the way our brain works. This means that we're all prone to certain fallacies when making decisions ! These are the four common fallacies which he highlights. The first is called framing . When exactly the same information is presented to you , how you make a decision will be strongly influenced by the way the information is presented to you. Just like a certain picture can look particularly attractive because it is mounted in an attractive frame ( rather than because it has an intrinsic artistic merit) , advertisers and marketers can subtly influence what you decide, by presenting information in a particular format ( or frame). This can be both positive and negative - and depends upon their playing with words ; or with numbers. Websites which promote "natural treatment options" for treating fertility are masters at this art !

Thus, instead of saying 51 percent of patients responded to treatment , they will say - the majority of patients improved with treatment ! It's easy to fool patients , so they come away with the wrong impression. It's only when you're aware of this framing fallacy that you can be on your guard and look out for it.

The most important numbers you need to find out are :
1. NNT , or number needed to treat . This is the number of people who need to be treated , in order to improve .
2. NNH, or number needed to harm . This is the number of people who need to receive treatment in order to suffer side effects .

It's important to compare apples to apples - and you need to make sure that the people who are being studied are similar to you - they should be age-matched; and have a similar severity of their disease.

You must remain alert to the fact that framing numbers can result in cognitive pitfalls and biases and the best way to overcome this is to be aware of these. You may need to drill down to get to the meat of the information presented to you, so you can focus on the steak and not get carried away by the sizzle !

The second bias is called aversion loss ; and arises because most of us regret potential losses far more than we care about potential gains. You need to be aware of this fallacy when you make decisions about your health. Sometimes we are so scared about losing something ( for example, your ability to have sex, ) that we may go over the top and make a decision which helps to minimize the loss , but may not always be the most rational decision . The third cognitive bias is the fact that our decisions are often skewed by what he calls the focusing illusion . When we try to think about the future , we often focus on just one particular aspect which could be negatively affected. This becomes such a dominant feature in our decision-making , that we forget that we have enormous resilience and can adapt and have a satisfactory life ( even if we can't have sex anymore, for example) . Finally , there is the availability bias. When something is "top of mind" and easily available, this sways your decision making process. This is sometimes why listening to stories from other patients can result in making decisions which are heavily influenced by what happened to that particular patient. This is why infertile couples are more likely to do IVF treatment ( which they may have resisted for many years), when they meed a friend or a relative who has just had an IVF baby. Being aware of your biases will help you identify certain fallacies in your decision-making process so that you're more likely to make the right decision, rather than than do this in a haphazard disorganised fashion !

Why do patients make the wrong decision sometimes ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 08 Feb 2012 12:58:00 +0000

Does exercise help to increase IVF success rates ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 08 Feb 2012 03:10:00 +0000

It’s common knowledge that exercising and maintaining a healthy diet are key to keeping healthy. However there is little research as to whether exercise can help with In Vitro Fertilization (IVF) or not.

Here are some reasons that maintaining a good, but moderate level of physical fitness may help:

Being overweight can prevent pregnancy

Having too high a BMI (body mass index) can lead to problems getting pregnant and staying pregnant. Obese patients have an increased risk of suffering miscarriages; and having polycystic ovarian syndrome (or PCOS), which can which cause infertility. Overweight women have a lower IVF success rate; and many clinics will insist that your BMI be normal before starting IVF treatment for you.

Being underweight can prevent pregnancy

On the converse side , being underweight also has a negative impact on your ability to get pregnant. This is because not enough estrogen is produced in women who are underweight, something that could negatively impact any attempts at getting pregnant – naturally or through IVF or other alternative fertility treatments.

Exercise During IVF

Harvard Medical School Researchers conducted a study on the relationship between exercise and IVF and surprisingly found that exercising too much could reduce IVF success rates . Strenuous exercise (such as running or other high impact activities) decreased the likelihood of IVF success. If you do need to exercise during IVF, it's best to focus on lower impact exercises.

Healthy Bodies Promote Success

It all boils down to being as healthy as you possibly can to improve your chances of successful IVF. Being unhealthy, whether you’re overweight, underweight, can all contribute to having an unsuccessful experience with IVF. Instead, women who are trying to conceive should focus on moderation and can achieve this by engaging in low-impact exercises such as walking or easy yoga, having low stress levels, and maintaining a healthy and nutritious diet .

This is all common sense advise - but because you are going through IVF , this is a great opportunity to optimise your health, because you likely to be highly motivated !

Author Bio:-
This is a guest post by Coleen Torres from local phone service. You can find more about her at her profile.

How patients think

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 07 Feb 2012 11:57:00 +0000

I have always been fascinated by why different patients make completely different kind of decisions , when faced with exactly the same problem. Thus , there will be patients who will happily resort to IVF when they have a fertility problem ; land on the other hand, there will be those who will spend 10 years taking homeopathic medicines in order to improve their fertility . I just read this great book, called, Your Medical Mind , by Dr Jerome Groopman . He's the author of the book , How Doctors Think - and I think a better title for this book would have been - How Patients Think .

In today's world , there's a lot of emphasis on what is called evidence-based medicine . Administrators are trying to force doctors into straitjackets and want to ensure that doctors blindly follow standard algorithms and protocols . Doctors are being forced to function as assembly line technicians , so that the care which they provide is no longer patient centered care, but system centered care. Unfortunately , bureaucrats don't realize that evidence-based medicine is really not the solution. What we need to practice is judgment-based medicine , where doctors can use their judgment to make the right decision for their patient.

The reason the mindless application of guidelines causes so much angst to doctors ( and distress to patients) is that they do not take into the account the patient's personal preferences and opinions about the various treatment options . The great thing about this book is it provides a lot of clarity as to how we can systematically factor in the patient's worldview , so that we can make individualised decisions which are right for each patient.

Doctor Groopman believes there are three important variables which impact a patient's medical mindset or worldview. All patients need to figure out for themselves where they stand.

First, there are patients who are technologically oriented , as contrasted to those who are naturally oriented . The ones with a naturalism orientation will use natural healing techniques and alternative medicine ; whereas those who have a technology orientation prefer using the procedures with high-tech Western medicine offers.

Secondly, there are maximalists versus minimalists . Maximalists are those who want everything possible done for them - versus minimalists , who believe in the wisdom of the body , and would rather allow the body to heal itself . They prefer letting nature take its own course and are very conservative.

Finally, there are the believers versus the doubters . The believers have faith that there is a solution for their problem - and that it's just a question of finding it. Doubters are typically skeptical and cynical - and are often paralysed when they need to make decisions, because they find it hard to trust anyone or anything.

There is no particular mindset which is better or worse. You simply need to know what your particular mindset is , so that you understand what your biases are , and can make the best use of your worldview. This will also help you understand that there are alternatives , which might actually be better for you , given the particular set of circumstances you find yourself in .

The final variable which patients need to consider is how much control and autonomy they want when they are making their medical decisions. Some patients are fiercely independent ; and want to decide everything for themselves ; while others are quite happy to let the doctor decide for them.

This is a great book for both doctors and patients . It will help patents to understand why there is sometimes so much difference between the opinions they get from different doctors . Don't forget , doctors can be maximalists and minimalists and doubters and believers as well - and this will colour the advise they give you ! It's a great book for doctors as well , because it'll help them to understand how and why they think; and why the patient sitting in front of them may have a different perspective. They can use this framework to help their patients make decisions which are right for them.

When should I stop trying IVF?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 07 Feb 2012 03:09:00 +0000

This was the plaintive question posed to me by a patient who had had failed four IVF cycles and had come to me for a second opinion. Should I do a fifth cycle doctor ? Shouldn’t I just forget about it ? Haven't I done enough already ? Haven’t I put myself through enough ? Haven’t I taken enough shots ? Changes enough doctors ? gone to enough clinics ? This is really getting too stressful - and I'm not sure whether it’s even worth trying again. Is it worth putting myself through all this stress and pain just to have a baby ? Is there any hope of IVF working if four cycles have failed ? What can you do differently ?

These are common questions IVF patients ask ; and the reality is we don't have any answers to them. Just because four cycles have failed , does that also mean the fifth cycle will fail? The chances of the fifth cycle working do not increase because of the four earlier failures – but neither do they decrease ! It's effectively a new lottery ticket - and the patient has to go through the decision-making process all over again . It’s a hard process and I don't think that I have the answers .

A lot really depends on the personality of the patient ! Typically , when we were kids , we were taught the importance of tenacity and persistence. We all know the story of King Bruce and the spider - and how we should keep on trying and trying again , until you finally succeed ! That logic is fine when you're studying for an exam or preparing for an interview - but does the same logic apply when you're doing something like IVF ? Unfortunately biological systems don't often follow logic , and it's important that everyone needs to draw their own “ laxman rekha” , their personal limit, so that they don't cross it before going to pieces or breaking down . Each person’s laxman rekha varies and depends upon many factors - emotional resilience ; personality; finances; temperament; social support mechanisms ; and how stable the marriage is .

You need to go through a lot of soul-searching before you make a decision , knowing full well that there is no easy answer no single right decision which applies to everyone - but that whatever decision you come to and find for yourself will be the right decision for you.

Are patients dumb ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 06 Feb 2012 11:53:00 +0000

I had a very interesting conversation recently with a friend of mine. He is a doctor who practices in a government hospital , and it was amazing how different our perceptions about the intelligence levels of our patients was.

I feel that patients are smart and very capable of making their own decisions for themselves. My worldview is that patients have a lot at stake and will do their best to understand what's happening to them and would rather make their own treatment decisions, rather than leave everything up to the doctor. I believe that if patients cannot understand what I'm saying the fault is mine – this means I'm not doing a good job with explaining , and need to try again. I have created a number of audiovisual aids and use these frequently in order to teach my patients about their infertility problems and the treatment options. Not all my patients are CEOs – many are illiterate and uneducated – and we try to teach everyone who comes to us.

My friend , on the other hand , believes that patients are not smart enough to understand about their medical treatment options. He feels that most patients would rather not break their heads trying to make sense of the complexities and nuances of medical decision-making, and are quite happy to let the doctor make these decisions for them

I think both my friend and I are reasonable, intelligent people - and yet we have such markedly different worldviews. The reason for this is that we deal with completely different patient populations. My patients are often articulate, smart CEOs of companies , who are used to deciding for themselves . They routinely exchange e-mails with me. He , on the other hand, has to deal with the masses of the unwashed majority within an outpatient setting in a public hospital where he has to see over 30 patients in the space of two hours.

I can sympathize with the pressures which he needs to work with. But just because his patients come from a lower social economic status does not mean that they are dumb ! In fact his patients are likely to be far more street smart. They live under conditions of poverty and deprivation in which I would not be able to survive for even one week. I think we need to give credit to the ability of our patients to understand for themselves ; and we need to acknowledge that is part of our job description to create educational materials for our patients. I think it's ironic that I spend so much time and money creating educational materials for my patients , who are already quite well informed and capable of accessing the Internet and getting tons more information if they want to . Isn't it tragic that he has not spent any time or energy in creating educational materials for his patients who need these far more, because they don't have any access to these materials at all.

He actually has the resources and the time and the energy to do so because he works in a teaching hospital and has lots of medical residents and medical students who work for him. I just wish doctors would accept that part of the job description involves educating patients and would be willing to spend the energy in order to do so.

Ironically, his creating educational materials would have a far better return on investment as compared to anything I can do , because he sees so many more patients ! However , he feels he's so busy providing clinical care to the patients he has to see on a daily basis, that he cannot find the time to do so. I think this is just a question of setting priorities and deciding that it makes more sense to treat patients as intelligent partners so that they will then be able to do a better job , rather than to complain about a paucity of resources. Let's not forget that patients are the largest untapped healthcare resource and we need to be able to give them the tools so that they can behave intelligently

I think the only reason doctors think that patients are dumb is because we treat them as being dumb; and we don't make any effort in order to try to get them to become smart. ( Or maybe smart doctors have smart patients and dumb doctors have dumb patients ?) This is a tragedy but it's actually an opportunity in disguise ; and I do hope that the next generation of younger doctors and entrepreneurs will take up this challenge !

Why patients need to do their homework !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 06 Feb 2012 03:08:00 +0000

I saw a patient today who had been taking treatment for the last two years; she had had irregular cycles which is why her doctor had put her on medicines for ovulation induction. However, she had not done any tests to find out whether her tubes were open or not !

When I asked her – “ Why haven’t you done a hysterosalpingogram ( HSG) to check your tubal
status ? “, the answer was one which I’ve heard many times in the past – “I didn't do it because my doctor didn't tell me to do it “. I explained to her how important this basic test is - that you really can't proceed with treatment without establishing whether the tubes are open ; and just because the cycles are irregular does not mean that we can automatically assume that your tubes are fine .

She got very upset and started blaming her doctor . If it's such a basic test, then why didn’t my doctor tell me to do it ? I don't think that's a satisfactory answer anymore in this day & age, where there is so much information available on the Internet for patients , that patients who are interested can easily educate themselves and arm themselves with the right information, rather than leave everything upto their doctor.

Blaming the Doctor doesn't really help anyone - and the damage which has been done to her by wasting her time is something for which she's the one who's paying the price - not the Doctor. It's important for patients to do their homework - not doing your homework can prove to be extremely expensive I think the problem is patients tend to underestimate their intelligence . They think doctors are extremely smart and know everything . Yes, doctors know quite a bit - but you are smart too , and you need to become an expert on your personal problem. You don't need to become a doctor , but you should be finding out about all your options and understanding what your choices are , so you can discuss these intelligently with your doctor .

Doctors are human , and they can make mistakes ; but expert patients , when they partner with their doctor will make sure that the doctor doesn't allow errors to occur , or things to fall in between the cracks .

The problem with modern medical imaging

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 04 Feb 2012 03:25:00 +0000

There is no question that medical imaging is one of modern medicine's most dramatic success stories. With today's MRIs scans we can image practically every part of the body with
stunning clarity and make diagnoses which were possible only at the time of doing a postmortem in earlier days. However, being able to probe into the body’s hidden recesses and get extremely clear pictures of the interior has actually created its own set of problems.

Let me explain. Let's look at a patient who has a lower back pain. Now if you have a back pain ( which most of us have had at some point in our life ), we learn to live with it. We take painkillers to deal with it when it becomes acute ; and do exercises and yoga and physical therapy to help us to get better. Lots of these problems are self-limited and will get better on their own , no matter what – sometimes with bed rest, sometimes with cold compresses and sometimes with physical therapy. However, when it becomes acute, or when your wife starts worrying that you’re not improving , you go to a doctor .

Your doctor obviously needs to do something more than what you already tried - something more than the standard home remedies , so he sends you for an MRI scan, to make an “accurate diagnosis” . Now the MRI scan will give you beautiful images of your intervertebral discs and the spinal cord – and will invariably show that you have a prolapsed intervertebral disc. Your doctor will be very pleased with himself – “ See ! I made the right diagnosis . This is the reason for your backpain !” Since his job is make a diagnosis , this gives him a thrill, because he's identified the problem with the help of medical imaging . Not only is the doctor happy with himself , his patients are also extremely impressed ! The doctor made the right diagnosis – and the MRI confirmed it. The patient can see for himself , in clear black and white , exactly what his problem is on his own scan.

However , because doctors are so focused on diagnosing problems , they actually don’t realize the downside of all these imaging results. Once the patient has seen a prolapsed intervertebral disc on his MRI scans he now stops focusing on his back pain and starts worrying about this lesion. He treats himself as a patient, someone who’s “ broken “ his back ; or someone has a weak back , and needs to rest – someone who can't play tennis or do the regular physical work out he used to in the past (when he had back pain , but before he had done the MRI scan. ) Once he's done an MRI scan , he now has a mental image that his body is broken , so that it doesn't work properly . He thinks of himself as being an invalid , and can't function properly anymore.

The tragedy is that these medical imaging procedures cause patients to focus on the problem rather than on getting better - and unfortunately, there's very little doctors do about this. Rather than sit and explain to the patient that a lot of these lesions will regress on their own; that they have a dynamic natural history ; that the body can heal itself and that many will get better on their , they will often advise the patient to repeat the scan every six months , to see how well the lesion is healing. Patients will often comply , just to see how well their disease is doing. The reality is that a lot of these lesions seen on the images have no correlation with either the symptoms or the progression of the disease ; and while they make great pictures for the doctor’s album they often don't help the patient at all !

Adoption - the old and the new

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 03 Feb 2012 02:51:00 +0000

Adoption is a great way of building families for infertile couples. This is an option which is been available through the ages , and many infertile couples feel that in case their IVF treatment cycles fail , they can always adopt a baby. However, the reality is that adoption has actually become much harder than doing IVF treatment !

This is because there just aren’t that many unwanted babies available for adoption anymore. This is true even in developing countries such as India, where women are becoming more educated and are no longer having unwanted pregnancies because use contraception ; and will terminate unwanted pregnancies . As a result, there are very few babies who are given up at birth or abandoned, which means there just aren't many babies left for adoption anymore.

This is good , because you don't want babies to be abandoned , but what happens to all the infertile couples who want to adopt babies ? Where do they go ? The fact remains that waiting list are now routinely anywhere from 2 to 3 years long - and even after being on the waiting list, there’s no certainty that couples will get the baby which they want.

The good news is that technology has come up with a clever solution , so that instead of doing a post birth adoption of a child, it’s now possible to do an in utero embryo adoption. This actually has a number of advantages as compared to traditional adoption . For one thing, there are no waiting lists because frozen embryos, which have been donated by other infertile couples who have got pregnant and don't want any more babies , are fairly easily available all over the world . Even better , it allows the mother to experience pregnancy and to bond with the baby . From a social point of view it's better because no one else is aware of the fact that your baby was conceived as a result of embryo adoption. This means that the name on the birth certificate is yours, so that there are no long-term issues as regards legal inheritances . Equally importantly, there is no problem with the risk that the baby may have suffered in utero because the mother ( who is going to abandon her baby at birth) did not provide the baby with the right antenatal care. For example she may have smoked should have abused drugs or alcohol because she was an irresponsible mother who didn't want the pregnancy in the first place. After birth , a lot of babies which are handed over for adoption are forced to spend about 3 to 6 months in an institution. Now this can't be very good for them and it does have an adverse impact on their emotional and mental development . The advantage with embryo adoption is that it's possible to bypass all the problems associated with traditional adoption , so that infertile couples can get the baby they want without having to go through the long and convoluted process of traditional adoption.

Times have changed and we need to change with them – and this is all for the best.

So what do I do next Doctor ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 02 Feb 2012 02:22:00 +0000

I often see patients who are at a crossroads after having failed 3 IVF cycles . They are confused as to what to do next. Should I try another cycle ? should I use donor eggs ? should I use a surrogate ? should I change my doctor ? should I do a blastocyst transfer ? They have lots of questions - and they often not sure what the best option is !

By the time they have failed 3 IVF cycles , they’re pretty well read and well informed - but often more confused , because there are so many different doctors and different websites giving diametrically opposite information, so it’s very hard to make sense of it.

Do you trust the anecdotal story of your online bulletin board friend who conceived after taking intravenous immunoglobulin or do you trust your doctor who tells you intravenous immunoglobulins are expensive hocus-pocus and just a waste of money. How is a poor patient to decide?

While I cannot give a straightforward simple dried cut and dried formula for how to make the right decisions , there is a simple process which needs to be followed to make sure that you make the decision which is right for yourself. Do remember that there are no right answers which apply to everyone - there are only answers which are right for you - and you need to find these for yourself.

Step number one is to think logically . Use left ( intellectual) part of your brain , to make a matrix of all your options – the cost ; pros and cons , and so forth . Step number two is to use your right brain , so you can decide which among these options appeals the most to you . You need to order these - which is Plan A ? and which is Plan B ? Which would you prefer to do if you had all the money and time in the world ? and which is the last possible thing you’d want to do , but would do if you were forced to do it and didn’t have any other choice .

Finally , the third step is to work out the logistics after you’ve done the first two. The commonest mistake patients make when they're making treatment decision is that they first try to work on the logistics. How much will it cost ? Can I afford it ? Which doctor should I go to ? How many days leave should I take ? Will I be able to fit it in my work schedule ?

This is the wrong way of doing things , and because they start off in the reverse direction , they end up making a mess of the decision. Start with a clean slate - and imaging what you would do if you had no limitations ; all options ; and all possible resources under the sun. Then start thinking about what would I like to do first . That’s where a bit of brainstorming and creativity comes in . You then gradually start restricting yourself based on real life constraints, so you can come up with realistic options , which are workable for you . If you use a systematic approach , your ability to come to the decision which works best for you is extremely high , as compared to a haphazard procedure which seems to depend more on what articles you read or which friend you have spoken to last !

The Health 2.0 conference in India

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 31 Jan 2012 10:46:00 +0000

I've just come back from attending the Health 2.0 India Conference held in Delhi. The conference was a lot of fun and I enjoyed myself thoroughly. The format is extremely interesting , because they compress a lot of information in a small amount of time without ever letting it get boring . For example , the demonstrations are just four minutes ; and the panels last for about 1 hour, so attention does not flag.

The themes are intriguing ; and I was very impressed with the ability of the Health 2.0 conference organisers to get such a diverse group of people with such different interests all together on one platform . These are people who come from various different backgrounds - designers; software geeks - and even some doctors ! ( The pharmaceutical companies were notable by their absence - it seems that they do not think they are in the business of providing healthcare ! )

They all share one passion - How can we use our skills to be able to provide better health care - whether the healthcare is for someone who is a multimillionaire living in Bombay ; or someone who works in a small village in Rajasthan. The common denominator seems to be the clever use of technology and it was quite interesting to listen to these presentations . I enjoyed the chance to meet people from all across the world, all of whom work in the same area - this bolsters your confidence that this is work which is well worth doing !

The star of the show was Mr Anil Swarup an Indian government bureaucrat who's actually completely revolutionized how health insurance can be delivered . Thanks to his innovative scheme, the Indian government actually provides health insurance for over 90 million poor illiterate people . They need to pay less than 50 rupees to sign up; and do not have to fill up even a single form ! This is something I will blog about more later, but what I really liked about him was his can-do attitude and his positive infectious enthusiasm !

Why doctors should let patients decide for themselves

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 31 Jan 2012 03:14:00 +0000

I recently saw a patient who came to me for a second opinion . She was advised IVF treatment and a workup showed that she had an endometrial polyp which was about five millimeters in size . She'd gone to another doctor , who advised her to get the polyp removed before doing the IVF treatment . This is one of those gray zone areas of medicine where it's always very hard to make a definite decision because different doctors have different opinions as to what needs to be done. Most doctors would take the approach that anything inside the uterine cavity needs to be removed before putting an embryo inside the uterus ; and they would automatically and reflexively suggest an operative hysteroscopy to remove the polyp before doing the IVF cycle. This is standard medical advice and is perfectly reasonable. However, there are other doctors who feel this is unnecessarily aggressive , because there is no proof that a small polyp can affect embryo implantation. This is a vexed issue which is very controversial because there aren’t enough studies to be able to come to a definitive conclusion. This is hardly surprising. Most IVF specialists will see only infertile women , so any time they see someone with a polyp , they will assume that the polyp is the cause for the infertility and will advise removal. However, the fact remains that lots of fertile women will also have endometrial polyps , which neither they nor the doctor will ever find out about , because they have enough sense not to go to a doctor to get this diagnosis !

So what is the doctor to do ? and what about the poor patient ? She gets conflicting advice from different experts, one of whom advises surgery and the other one advices you don’t need to do anything at all about it. This is the kind of situation where information therapy is extremely potent . We need to empower the patient with information so the patient can decide for themselves.

What I usually do is explain both options to the patient along with their pros and cons. While this works well with educated, intelligent patients who are capable of making a decision for themselves , there are lots of patients who don't like this approach. For one , they think I’m wishy -washy ; and for another they conclude that I don't know what to do myself , which is why I'm asking them for their advice ! In reality , I’m not asking them what to do - what I'm helping them to do is to come to a decision which they feel will be right for them.

At the end of the day , outcomes are always uncertain. It's not that removing the polyp will guarantee IVF success ; while keeping the polyp will not mean that the IVF cycle will fail. However, there are some patients who are petrified of surgery and will do anything to avoid it. On the other hand , there are patients who are very sure that they want to maximize their chances of success by removing all possible obstacles and hurdles ( no matter how speculative) which may come in the way of their IVF cycle succeeding.

The trouble is a doctor can’t read a patient's mind which is why we need to ask patients to provide their inputs ; and we need to factor these inputs in when we make a decision. I always tell patients the buck stops with me. After all , I am the professional and since I am the doctor , I guarantee that I will never let them make a wrong decision . On the other hand, when there are choices , I encourage them to apply their own mind and to provide their personal inputs , so that we can jointly make a decision which is right for them.

Why patients need to become experts !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 30 Jan 2012 03:13:00 +0000

I saw a very interesting patient today. She’d been referred to me by a gynecological oncologist who had made a diagnosis of early endometrial adenocarcinoma and had sent her to me because she wanted to find out what her reproductive options were. This was a young 24-year-old woman with polycystic ovarian disease who had just got married six months ago. She had gone to a doctor for an evaluation because she had heavy menstrual periods and the doctor found she had a uterine polyp , which is why she performed a hysteroscopy . Much to her dismay , when the histopathology report came back , it showed she had complex hyperplasia with atypia with early endometrial adenocarcinoma .

Further evaluation showed this was a localized cancer with no invasion , and she wanted to know whether it was possible for her to conserve her uterus because she wanted to complete her family. Now the standard advice in this situation is to go ahead and do a hysterectomy. This is what most doctors would advise because it is actually much safer for them. For one , it's standard medical advice. After all , when you have cancer , you remove it - who can argue with that ? For another, it actually helps to protect the doctor ! In case the doctor does not advice surgery and then the cancer spreads , the patient may come back and sue the doctor for not advising surgery in the first place. This is why many doctors are quite reluctant to advise nonstandard approaches - because of the fear of being sued.

My approach was simple. I told the patient you are going to have to become an expert on your problem. Not only will you have to learn a lot about endometrial adenocarcinoma and its treatment options , you are going to have to learn about polycystic ovarian disease and fertility and infertility and IVF as well. The trouble is that I'm an IVF specialist and don't know much about endometrial cancer - whereas your gynecological oncologist knows a lot about the endometrial cancer , but may not know much about IVF , which is why you need to inform and educate yourself. Not only do you need to understand the alternatives and options , you also need to provide your own personal preferences and inputs so that you make a decision you’re comfortable with.

The outcome for any treatment is always going to be uncertain , and you don't want to beat up on yourself later on that you made a decision without having all the right inputs. Patients need to make a decision matrix of what their options are and then think through their personal preferences, so they can come to a conclusion which they comfortable with. It’s very helpful to document this in writing , so that patients can systematically walk their way through all the steps . Their doctor also is protected , because he can document that he’s explained the pros and cons ; and the patient has provided informed consent before making a decision which may have outcomes , some of which are likely to be unfavorable to the patient.

Unfortunately, few doctors in India take this approach. Most of them prefer being paternalistic – their approach is that patients come to us with their problems because we are the experts ; and it's our job to provide solutions ! They will often provide just one simple solution with a black-and-white approach and then tell the patient - You can either accept this solution if you want to come to me ; and if not, you can find another doctor and go somewhere else. While this is a straightforward approach and something which works well for some doctors , it is not one which I'm comfortable with myself because it doesn't allow the patient to play any role at all in such a complex decision-making process which will affect the rest of her life !

HELP on the CNN IBN India Positive Show

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sun, 29 Jan 2012 02:52:00 +0000

HELP was featured on the CNN IBN India Positive Show

Science, IVF and God

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 28 Jan 2012 03:03:00 +0000

An online patient asked me a very intriguing question recently.

" Do you think a superhuman power plays a bigger part in deciding whether the embryo should implant or not? From your experience as an IVF doctor for several years whats your conclusion after seeing so many IVF cases - or do you think its just science, probability and luck? Have your ever noticed any difference in a successful patient's mentality and an unsuccessful one?"

In all honesty, this is one of those questions no one has an answer to. We can only guess. All IVF doctors will agree that IVF is not a precise science - and we can never predict the outcome of any treatment cycle, no matter how well it goes.

The truth is that being human, we are all inclined to repose our faith in a higher power, especially when we are in trouble ; and are struggling ( for example, when tackling with infertility) and need help. This is a normal response, as we try to make sense of life when bad things happen to us. However, whether a belief in God actually helps to improve IVF outcomes is highly debatable. While some studies claimed that praying helped to improve medical outcomes for some patients, there is no evidence that this will really do so .

IVF is one of modern science's success stories ! It allows us to do in the IVF lab which is not happening normally in the bedroom. When nature fails infertile patients, science comes to their rescue . So where does God fit into this ? Is IVF unnatural and interfering with God's plan ? Are IVF doctors playing God ?

The relationship between God, science and spirituality is pretty complex. Many infertile patients believe God is punishing them by not giving them a baby ( this is especially true if they have done a termination of pregnancy earlier). Others are happy to benefit from what science offers them by making use of IVF technology - but will also go to a temple before doing IVF, to cover all their bases. This helps them because science does not have all the answers; and there's still lots of stuff we do not understand.

A belief in God helps you cope with the IVF emotional roller coaster ride. It's easier to deal with ups and downs when you feel that a higher power is looking after you ! When you learn that doctors don't always have all the answers, it's comforting to believe there is someone who does. This is why many IVF patients turn to God during their IVF treatment.

Others will turn away from God, especially when their IVF cycle fails. As it is their faith in God is shaky, because their first question when they find out they are infertile is always - Why Me ? They feel God has let them down by picking on them - and when he fails to come to their rescue by allowing the IVF cycle to fail, they feel he has forsaken them - and promptly lose what little faith they had to start off with. Lots of patients are very inconsistent. They are happy to do their best to placate God when they feel this may increase their chances of success - but when the IVF cycle fails, they lose all faith in him. This difference in worldviews can be quite a problem when the spouses have diametrically opposite viewpoints !

Does being spiritual and having a belief in a higher power help people to remain more positive ? Or does being scientific and rational help because it's easier to come to terms with failure when you know you've done everything which medical science has to offer ? What's your opinion ?

Why do so many women stop treatment after failing their first IVF cycle ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 27 Jan 2012 02:31:00 +0000

Most infertile women know that IVF represents their best chance of having a baby, which is why they sign up for the first IVF cycle. Those who have realistic expectations understand that the failure rate in one cycle will always be more than the success rate, which is why they should be prepared for the fact that they may need to do a second or third cycle before they achieve their goal of having a baby.

However, we find that once they have failed an IVF cycle , many women just stop doing anymore treatment. The dropout rate in IVF treatment is extremely high and it’s worth trying to figure out why this happens. In a perfectly rational world , once a women decided to do an IVF treatment cycle , logically she would continue doing the treatments until she finally achieved her goal of getting pregnant. This is why , if the first IVF cycle fails , she should be both mentally and physically prepared to do a second . However , lots of patients decide not to do a second cycle and there could be many reasons for these - some rational and some not so rational.

Some people can't afford to do a second cycle for financial reasons because they've run out of money . That is a perfectly rational reason . Other patients may find the experience too emotionally draining or too stressful , which is why they don't want to put themselves through it again . I guess that's a perfectly rational explanation as well , but surprisingly, there are some who could afford to do another cycle and don’t find the experience too hard to deal with, who decide that just because their first cycle failed , they are not going to try a second cycle. This is partly because they're worried about how much money they’ve already wasted on the first treatment; and partly because their confidence in IVF treatment has been shaken up , because the first cycle failed.

Patients have excessively high expectations of success in the first IVF cycle for many reasons. They have high hopes that this is the magic solution which will give them their longed-for baby . The press is also responsible, because it highlights only the IVF success stories, and does not talk about the failures. Doctors are also responsible for this misplaced optimism, because they try to present as rosy a picture as possible , in order to “hook” the patient. The downside to all this is that when the cycle fails , it's very hard for some of these patients to recover . They then decide not to pursue IVF treatment at all .

Sadly , they’ve actually made their own bad situation even worse because a second or third IVF cycle would actually be their best treatment option , purely from a logical objective point of view. However, humans aren't always rational and we make decisions which we then regret later on , as time goes by.

The best way of preventing this kind of situation is :
a) for patients to have realistic expectations before they start the cycle and
b) to be prepared for the fact that success may involve more than one or two attempts.

This is why guaranteed pregnancy option programs are so useful ! It’s not because they end up saving the patient's money , but because they help the patient to reframe their perspective and understand that IVF treatment may not always succeed at their first try. Patients who enroll for these programs are mentally prepared to invest as much time and energy in their treatment as is required for them to achieve success, rather than to think of it as a single shot hit or miss affair.