Dr.Malpani's Blog

IVF Promises a Bundle of Joy

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 18 Jun 2013 11:57:00 +0000

Instead of wasting time with ineffective procedures that score low on success rate, many patients are opting to go for IVF, to maximise their chance of living their dream of healthy baby

“Technological innovations which simplify IVF and make it less expensive are going to be very important”

In the past, In-Vitro Fertilisation (IVF) was often the method of last resort for infertile couples. There were very few clinics which had the equipment and expertise to offer this advanced technology; the success rate was poor; and there were many myths and misconceptions about what was involved in the treatment. After recent spectacular advances in reproductive technology, IVF has now become the treatment of first choice for solving many infertility problems, because of its high success rates. There are now large number of IVF clinics, which means that this treatment is easily available.

http://ehealth.eletsonline.com/2013/06/ivf-promises-a-bundle-of-joy/

Doctor why did I miscarry ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 17 Jun 2013 12:00:00 +0000

Miscarriage is always an emotionally painful event. When you are looking forward to having a baby, they losing the pregnancy can break your heart. It's much worse for infertile patients ! After all that waiting, when you finally get a positive pregnancy test, you are over the moon and start looking forward to holding your baby. However, if you then end up miscarrying, this is extremely cruel, because when someone gives you something and then snatches it away, it's much harder to cope with the pain and heartache.

Sometimes patients are confused as to what actually constitutes a miscarriage. A lot of them think that once a pregnancy test is positive ( when the hCG blood level is more than 10, this means that they are pregnant ; and that if this level drops, they have had a miscarriage. This is not true a positive.

Read more at http://www.drmalpani.com/doctor-why-did-i-miscarry.htm

Why do IVF patients feel the doctor cheated them when an IVF cycle fails

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 17 Jun 2013 11:30:00 +0000

When the cycle fails, IVF patients are understandably upset and angry and they need to vent their frustrations on someone. There are only 4 possible targets. They can get angry with themselves and curse their fate; they can curse God, for not giving them a baby; they can blame their spouse, for not supporting them ( for example, by not agreeing to do IVF when she was younger and had a higher chance of success) ; and, finally, they can get upset with their doctor. The doctor is an easy target and there are many reasons why patients will feel angry and cheated when an IVF cycle fails. Some of this has to do with the patient, and some has to do with the doctor .

Thus, when doctors sign patients up for IVF treatment, they are often overoptimistic because they are in "sell" mode. They promise the earth and the moon and talk glibly about their high success rates and how good their facilities are.

Read more at http://www.drmalpani.com/ivf-patients-feel-the-doctor-cheated-them-when-ivf-cycle-fails.htm

What to do if you and your spouse disagree about treatment options!

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 17 Jun 2013 10:32:00 +0000

When tackling infertility, you will be flooded with a variety of treatment options. The field of ART is vast, and depending on the nature of your problem , the treatment choices can vary all the way from simple ovulation induction with clomiphene to IVF and surrogacy.

With the advances in the field of ART, there is a solution for almost any kind of infertility problem you face, but being open to different treatment options is not easy for everybody. Not everyone is comfortable in subjecting themselves or their spouse to treatments which are not agreeable to them physically or mentally. Financial conditions, social, cultural and religious limitations and fear of medical procedures all play a major role in deciding whether to pursue a particular infertility treatment or not.

Infertility is more of an emotional ailment than a physical one ! The unquenchable desire for a baby combined with social and peer pressure are the most important driving forces which compel couples to undergo different infertility treatments. As long as both partners' couples are on the same page regarding pursuing a particular fertility treatment option, everything is well and fine. But what happens when they do not see eye to eye about their options ? What happens when one of the partner wants to put an end to the infertility treatment and move on with life, while the other person could not imagine a life without a baby ?

Read more at http://www.drmalpani.com/you-and-your-spouse-disagree-about-treatment-options.htm

Why don't Indian patients ask their doctors questions ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 17 Jun 2013 03:06:00 +0000

During the consultation, I encourage my patients to ask me questions . However , I often find that some of them are quite reluctant to do so , and I think this is for two reasons - one which has to do with patients; and the second which has to do with doctors .

Because most doctors don’t encourage questions, patients are not used to being told by the doctor to ask them questions ! This is why when I tell them to ask questions , they find this little bit startling and unusual and they are not sure how to respond . In a perfect world, doctors would routinely encourage patients to ask queries, so they could clarify their doubts . However, because doctors are so busy , this often becomes a counsel of perfection which is relegated to textbooks. In the real world, it’s hard for most doctors to do this, as a result of which patients usually bottle up their doubts and queries. However, when things go wrong, this can cause a lot of long-term dissatisfaction , because of unrealistic expectations. This is what leads to complaints from patients , and this is often why patients feel cheated because they feel that the doctor did he not give them all the information which they needed.

The second issue has to do with patients themselves . Patients have been brought up in a culture where they put doctors on a pedestal. They feel doctors know everything, and can be trusted to provide them with the right guidance . They are not used to doing their homework or finding out information for themselves ; or attempting to clarify details about the doctor’s explanations, even when this goes over their heads.

Because patients aren't used to doing this , when they encounter a doctor who asks them to ask questions , they are not sure how to respond. The good news is that on the second visit , patients are far better prepared ! Not only do their homework, they come with a list of questions - most of which they have been able to answer for themselves. But if there are some complicated ones they are not certain about, I'm quite happy to clear their doubts during the consultation !

Which is the best medicine for increasing a low sperm count.. ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 14 Jun 2013 06:33:00 +0000

One of the commonest requests I get is - Doctor , I have a low sperm count . Which is the best medicine to boost this ?

They try to manipulate their diet and their lifestyle , with the hope that something will work. Popular interventions include:
Cold water showers
Boxer shorts
Sexual abstinence
Lots of almonds ... it's a long list !

There are lots of myths and misconceptions about low sperm counts . Let's try to dispel these one by one.

Firstly, lots of men think they have a low sperm count , when in fact they don't ! This is because labs are extremely unreliable - and there are still many labs which report normal sperm counts as being more than 60 million per ml ! This means that a man who has a sperm count of 30,000,000 per ml ( which is completely normal) starts thinking that he's infertile because of a low sperm count ! infantile. However, the WHO has defined a normal sperm count as being more than 15,000,000 per ml - and if your count is more than this, and if your motility is normal, this means your semen analysis report is normal and you do not need any treatment at all ! Not only is this something lots of men don't understand , many gynecologists are also still not aware that normal ranges for sperm counts have changed so dramatically over the last few years, as our understanding about sperm physiology has improved . This means that a lot of men who seem to have a low sperm count actually have a completely normal sperm count and don't need treatment at all !

Read more at http://www.drmalpani.com/best-medicine-for-increasing-low-sperm-count.htm

I am an embryologist and I love my job !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 13 Jun 2013 06:16:00 +0000

Dr. Saiprasad Gundeti, Chief Embryologist, MALPANI INFERTILITY CLINIC PVT. LTD.

I am a Clinical Embryologist and I love my job. Every day, I get to help infertile patients and guide them through the challenging process of IVF, so they can hold their deeply cherished babies. I love using my science background and my spatial skills in performing what is a very demanding and technically exacting hands-on job.

What I do is an essential part of providing IVF services to infertile couples. As part of a multi-disciplinary team, I am involved in collecting the eggs, preparing sperm, checking fertilisation ,growing the embryos, transferring them; as well as freezing and storing them. The services I provide are directly linked to the success of IVF procedures - and how well I do them will determine the success rate of the clinic.
I am privileged, because I have the opportunity to see the joy in patient's eyes, when they see their embryos for themselves ! I also have provide patients with a shoulder to cry on ( for example, when their eggs fail to fertilise) - and I have a ringside view to the entire gamut of human emotions - joy, despair, hope and sorrow - and all this in a single day !

Read more at http://www.drmalpani.com/why-i-love-my-job.htm

Surgery for the future - enhancing function !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 13 Jun 2013 02:18:00 +0000

Typically surgery , has always been about correcting anatomical problems. If you broke a bone , the doctor joined it for you; if you had a tumour, he cut it out; and if you had an abscess , he drained it. In the future , surgery will become much more exciting , because rather than focus on fixing problems, clever surgeons and biomedical scientists will create procedures which will enhance function in normal people.

Thus, for example , functional neurosurgery will allow normal people to improve their memory while phonic surgery on the vocal cords will allow people who have a good voice to make it even better because of surgical intervention. This is a very tempting concept , because people prefer shortcuts and even though everyone understands that it's possible to improve your memory by studying harder; and that you can improve your voice by taking speech classes and practicing , this is not something which most people are willing to do because they don’t want to invest so much effort . If the surgeon can offer a safe and convenient shortcut which works , lots of people will be willing to pay for this.

There’s lots of money in this approach – and in one sense, this is a natural evolution. For example , when pharmaceuticals were first discovered , they were used to treat the sick. If someone had malaria , you treated them with antimalarials . Now, however, we use pharmaceuticals in order to enhance lifestyle quality , so we use drugs to improve people’s sexual performance or to make them happier.

In the past , psychiatrists would only concentrate on people with mental illnesses such as schizophrenia. Today, they're working on what they can do to make people happier ! The focus is moving from treating illness to enhancing health

We can learn a lot from plastic surgeons . Their original focus was on fixing surgically correctable lesions such as cleft lip and burns. Today, most plastic surgery is aesthetic, and is done on people who are normal but want to look better, which is why they are willing to subject themselves to the surgeon’s knife.

This is quite a logical progression. Thus, rather than merely replace worn out joints, orthopedic surgeons will develop procedures to enhance joint function - for example , by inventing procedures which improve the way tendons work , using carbon implants .

This makes a lot of sense for medical devise manufacturers as well because they can now address the need of a much larger population of possible customers ! This is an exciting time to be a surgeon !

Are patients stupid ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 12 Jun 2013 10:51:00 +0000

Sometimes doctors get very upset by how poorly informed their patients are . They find it very frustrating when patients know so little about their medical problems ; and they feel that the time they have to spend on explaining the basics of human anatomy and physiology to their patients could be better used making the right diagnosis or doing treatment procedures. They believe that every patient should have enough background knowledge about their own body – and cannot understand why patients are not willing to take the time and trouble to learn more about their most precious possession – their own body. The general perception amongst doctors is that patients are stupid and are not capable of understanding the basics; or that they are lazy and are not interested in finding out more. I think both of these are flawed perceptions.

The truth is that patients do want to know more about their illness and its treatment, but some of these topics and concepts can be fairly complicated , and it takes time for them to understand what's happening.

The right approach should be that it's not patients who are stupid or lazy but it's much more likely that it's doctors who are lazy , because they will not take the time and trouble to explain to patients in simple terms which they can understand. After all communication is always a two-way street and if the patient cannot understand what the doctor is saying, this means the doctor is not doing a good job in explaining to the patient.

This doesn’t mean that doctors are stupid – it just means that they are shortsighted and are not willing to look at things from the patient's perspective . They tend to jump to conclusions which are incorrect , and blame the patient for something which is actually a shortcoming on their part. Some doctors take perverse pleasure in making simple concepts complicated, because they want to show to their patient how erudite they are. Some doctors deliberately use this as a tool to put patients in their place, to awe their patients with the polysyllabic jargon which they throw at them .

I always tell patients that if you can't understand something which your doctor tells you, it’s not your fault – it’s your doctors, because this just means he does not know how to simplify and communicate !
Good doctors will take the time and trouble to teach their patients and ensure they understand – and the best doctors will create educational materials which patients will be able to comprehend , no matter how limited their current state of knowledge maybe.

After all, this is education is all about – taking the student from where they are presently, to where you want them to be. The good news is there are now lots of online resources which help patients to make sense of what's happening to them , so they no longer have to depend upon their doctor to teach them. Smart doctors are now “ prescribing “ this information to their patients, to create win-win situations, so that patients have realistic expectations of their treatment.

Decoding Medical Gobbledygook now available for the Kindle

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 12 Jun 2013 04:01:00 +0000

Our book, Decoding Medical Gobbledygook is now available for the Kindle !

Is bed rest after embryo transfer necessary ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 11 Jun 2013 07:36:00 +0000

Will moving after an embryo transfer cause my embryos to get dislodged from the uterus ? Does being physically active affect the ability of my embryos to implant ? Every woman undergoing the 2ww is very worried about carrying on with her routine daily activities, because of her fear that these will affect the outcome of her IVF cycle. To add insult to injury, many IVF specialists also ask women to take bed-rest after embryo transfer ! Does restricting normal activities make any sense ? Will bed-rest really help ? There are many scientific publications which address this issue.

These confirm that normal activity after embryo transfer has no adverse effect on embryo implantation. There is no difference in the IVF outcome, if a woman restricts herself to bed; or if she carries on normal activities after embryo transfer. Recent research in fact suggests that strict bed rest after embryo transfer might actually reduce the chances of conception ! Please carry on with your routine activities , but do not do anything which will cause you to blame yourself if your cycle fails.

Read more at http://www.drmalpani.com/is-bed-rest-after-embryo-transfer-necessary.htm

What every patient needs to know about the IVF lab

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 10 Jun 2013 12:00:00 +0000

Saiprasad Gundeti
Senior Embryologist, Malpani Infertility Clinic

The IVF lab is the heart of an IVF clinic because this is where we grow and safeguard your precious embryos. The IVF lab equipment and the skills of embryologist play a very crucial role in IVF treatment, but most IVF patients are clueless about what happens in the lab. Let me take you behind the scenes, so you can get a peek as to what the embryologist does in the IVF lab.

Why should you bother ? Not only is it very important for IVF patients to do their research, so they can understand which of the many modern assisted reproductive technologies available today are best for them - they also need to select the best IVF clinic to maximise their chances of success ! The clinic can be only as good as the lab is - so in order to judge the competence of the lab, you need to do some homework for yourself !

Read more at http://www.drmalpani.com/every-patient-needs-to-know-about-the-ivf-lab.htm

Pregnancy in a man with Globozoospermia

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 10 Jun 2013 11:57:00 +0000

Saiprasad Gundeti, Senior Embryologist

Here's a case study of a very challenging patient we treated recently. This man was diagnosed with globozoospermia with normal sperm count and motility.

Repeated semen analyses showed 100 % sperms with absent acrosome.

ROUND HEAD SPERM (GLOBOZOOSPERMIC SPERM)

He had had an earlier ICSI treatment cycle in another clinic which had failed. Unfortunately, no treatment details were available, as the medical details of the treatment performed had not been well documented.

The principal cause of fertilization failure after human ICSI ( in a good lab) is a deficiency in the oocyte activation mechanism. Oocyte activation typically occurs immediately following sperm-oocyte fusion and the master key to initiate these changes in fertilized oocytes is a calcium influx into the oocyte. The sperm factor phospholipase C zeta (PLCz) ,which is normally found in the acrosome, is considered to be the agent responsible for these calcium oscillations. If this is absent ( as in men with globozoospermia), then assisted oocyte activation needs to achieved by alternative means, such as by using a calcium ionophore ( as described below).

Read more at http://www.drmalpani.com/globozoospermia.htm

What makes an embryologist Grade A

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 10 Jun 2013 11:51:00 +0000

This is a guest post by Dr. Saiprasad Gundeti, Chief Embryologist, Malpani Infertility Clinic Pvt. Ltd.

Embryos are graded in the IVF lab routinely, according to their appearance ( morphology) under the microscope. Good embryos are called Grade A embryos, and have a higher chance of becoming babies.
The scientists who are responsible for taking care of your embryos in the IVF lab are called clinical embryologists . We are involved in fertility treatment and reproductive research and need a practical and theoretical understanding of human reproductive biology, embryology, infertility and assisted reproductive technology (ART). We also need to keep up to date with current regulations and legislation involving these subjects. Just like you have Grade A embryos and Grade B embryos, you have good embryologists - and bad ones. Unfortunately, patients don't know much about what happens in the IVF lab and what embryologists do, so this article will shed some light on the role we play in your treatment !

Read more at http://www.drmalpani.com/what-makes-an-embryologist-grade-a.htm

HCG levels after IVF

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 10 Jun 2013 11:47:00 +0000

Can the level of HCG in blood tell me whether my pregnancy is a healthy one or not?

Yes - but only to a certain extent. The HCG (human chorionic gonadotropin) hormone is a remarkable molecule which is very unusual because it is produced only by the cells that will become the placenta of the developing embryo (trophoblast cells). Once the embryo implants in the uterine lining, these cells start producing HCG. It takes a few days for the HCG hormone to build up in the body to a level, which is high enough for it be detected in the blood or urine of pregnant women. Normally, you do your first pregnancy test (HCG blood test) 14 days after embryo transfer.

At this point, if the embryo has implanted, you will also get a positive urine pregnancy test. The HCG hormone level in the blood doubles every 48-72 h. If the HCG level doubles well, this indicates that the cells of the embryo are dividing well, suggesting that the pregnancy is progressing normally and is healthy. This is why monitoring the HCG blood levels during the first few weeks helps to make sure that the pregnancy is advancing as expected. A drop in HCG level during this time is a sign that the pregnancy is not healthy. Make sure that you measure your HCG level in the same lab each time to avoid discrepancy in the results.

Read more at http://www.drmalpani.com/hcg-levels-after-ivf.htm

The 2 week wait and IVF

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 10 Jun 2013 11:43:00 +0000

Will my symptoms during the 2ww tell me whether I am pregnant or not ?

During the 2ww ( 2 week wait, from embryo transfer to the pregnancy test) it is very natural to wonder about the fate of the embryos which are transferred to the uterus. Every woman who has had an embryo transfer longs to know the outcome of her IVF cycle. Every minute of the 2ww lasts an hour - and the 2ww is the longest wait for any woman who has undergone IVF.

When going through the 2ww, women become aware of even the slightest change that happens to their body. " I am feeling warmer than usual; I have a tingling feeling in my breast; my nipples are sore; I could sense a muscle being pulled in my pelvic region; I have a strange vaginal discharge; I urinate frequently; I feel nauseous - does this mean I am pregnant ?" This is the question that lingers in the mind of every woman - whether they explicitly acknowledge it or not . This can be made worse by a worried spouse who solicitously asks every day - How are you feeling ? Many women constantly surf the web to read about the 2ww symptoms of women who got pregnant after an embryo transfer. Although this can make the 2ww interesting , and can help some women to cope with it, many women start to panic too when they do not experience any symptoms . Others start imagining that they are pregnant of if they have any of the about symptoms. Are there really any symptoms which could tell you whether you are pregnant or not , before taking a pregnancy test ?

Read more at http://www.drmalpani.com/the-2-ww-and-ivf.htm

HELP gets the Health Literacy Hero award !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sun, 09 Jun 2013 15:21:00 +0000

The Health Literacy Hero for June 2013 is HELP (Health Education Library for People) based in Mumbai, India. Founded as a modest-sized patient education resource center in 1997 by Drs. Aniruddha and Anjali Malpani, HELP is now India’s largest patient education center--housing thousands of books, pamphlets, health care magazines, and audiovisuals on all aspects of health and disease. HELP offers free public seminars in Mumbai nearly every day. HELP also provides an online resource center where users worldwide can ask health questions and search its vast medical knowledge base. Anjoo Chandiramani and her staff of librarians maintain the HELP collection. Here’s the link, http://www.healthlibrary.com

We are very proud that our efforts are being recognised globally !

Embryo transfer - mechanics versus biology

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 07 Jun 2013 06:38:00 +0000

Patients have lots of doubts and misunderstandings about the embryo transfer procedure and I'll try to dispel some of these.

We need to understand there are 2 separate components to embryo transfers. One is the mechanical procedure of physically putting the embryos back inside the uterine cavity through the cervix , using an embryo transfer catheter . The mechanics of an embryo transfer procedure are fairly easy and straightforward . It usually just takes a few minutes to transfer the embryos , and this is something which is performed routinely in IVF clinics all the time . A good IVF doctor is skillful. He transfers the embryos gently , and because he's patient , he ensures that little damage is caused either to the embryos or to the uterus. When doing this procedure , he need to be gentle and deliberate. Interestingly, even though it seems to be very simple straightforward procedure , there is a marked difference in the pregnancy rates amongst doctors who do the transfers . There are some doctors whose success rates are nearly 3 times as high as others , even though they work in the same clinic, and seem to be performing exactly the same procedure . We still do not understand why there is such a marked difference, but this is why it's a good idea to find a highly experienced doctor ! Doctors have tried improving the results of embryo transfer by doing the transfers under ultrasound guidance , so the doctor knows exactly where he is depositing the embryos, but whether this actually helps in experienced hands is still controversial .

Read more at http://www.drmalpani.com/embryo-transfer-mechanics-versus-biology.htm

Why pharma companies need to engage directly with patients

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 06 Jun 2013 16:24:00 +0000

" As a Customer Engagement Manager covering the Nordic region for Janssen Pharmaceuticals , Petteri Jarkka deals with multiple customers including the patient, payer and physician, in a role which combines marketing and patient engagement elements. As he explains, “this is a fairly new role which reflects a new direction for Janssen. Yet it also has something to do with the situation in the Nordic market, a very mature market with limited access to the physician. We’re averaging less calls than we used to, everyone is, even with Medical Representatives so clearly there is a greater need for customer-facing access and the use of multiple channels. I think we will see the same things happening more and more in other European countries as those markets mature.”

Pharma companies in mature markets like Europe understand the value of "co-creating" with their doctors and patients. Hopefully, mature pharma companies in immature markets like India will see the value in doing this as well !

Achieving a pregnancy after tubal sterilization

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 25 May 2013 07:21:00 +0000

Patients undergo tubal sterilization because they have chosen not to have any more babies. This is why they undergo a surgical procedure to block their tubes and make themselves infertile. However, as times change, so do people - and many women who had a tubal sterilization find that they want to have another baby - for example, if one of their children dies; or if they remarry.

Read more at http://www.drmalpani.com/achieving-a-pregnancy-after-tubal-sterilization.htm

Is there anything I can do to increase my ovarian reserve ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 23 May 2013 07:18:00 +0000

When a girl is born , she already has the entire stock of eggs she is ever going to produce in her life. Unfortunately there is no new egg production in the ovaries after birth , and we cannot coax the ovaries to produce new egg cells. During an IVF cycle, we just grow some of the eggs which are already present in your ovaries. Please do not believe the stem cell scam for increasing ovarian reserve - it is not sound science !

Read more : http://www.drmalpani.com/increase-my-ovarian-reserve.htm

How to get an effective second opinion

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 21 May 2013 02:30:00 +0000

Patients are often confused when exploring their treatment options. This is not surprising , because there are now so many choices ! When they are confused , they turn to their doctor for medical advice. Patients understand that doctors don’t have all the answers , which is why they will often get a second opinion to confirm that the advise which the first doctor gave was reliable or not. For example, if a patient has endometriosis, she goes to a gynecologist who advises her to do a laparoscopy to make the diagnosis and to treat the disease. She is understandably uncomfortable about subjecting herself to surgery, which is why she gets a second opinion from another gynecologist. When this doctors also says that a laparoscopy is the next step, since she has now been to two different doctors , both of whom arte advising the same surgery, she is comfortable that she is on the right track , and goes ahead with the laparoscopy. Unfortunately, this is flawed thinking. The trouble is that when you have a hammer, you end up seeing only nails ! Lots of gynecologists respond in a reflexive manner when they hear the word endometriosis . Their standard advise is to do an operative laparoscopy , in order to remove the endometrial lesions. Their worldview seems to be that the endometrial deposits cause fertility problems; and that whenever there is something abnormal, the best thing to do is to just take it out – just like all lumps in the breast need to be removed.

It’s quite easy to sell the patient on the idea of doing a laparoscopy. For one, it make logical sense. Isn’t it important that the doctor take a look inside the belly, so he can see exactly what’s going on ? Also, most doctor emphasise now easy laparoscopic surgery is today. It’s a simple procedure which does not leave a scar. It takes a few hours and the patient doesn't even need hospitalization because it’s” minimally invasive surgery “.

This is why a lot of patients with endometriosis end up doing surgery – and the surgery actually reduces their fertility ! This is partly because the endometriosis is minor – it’s a red herring which wasn't really affecting her fertility and could have been safely left alone. However, once the doctor is in the OR, he has to complete what he started. Along with removing the chocolate cyst, he also removes normal ovarian tissue , thus reducing the patient's ovarian reserve and causing her to become infertile !

This is the biggest tragedy of going to two ( or more) doctors of the same specialty for a second opinion. They share the same world view – and their advise is likely to be very similar. This is why you should actively seeks out a second opinion from a doctor with a different perspective ! You will get a much more balanced viewpoint, so that you can understand both the pros and cons of a given option. Thus, you should seek out an IVF specialist , who will try to convince you why you should not be doing a laparoscopy , and why you’d be better off doing IVF instead.

It’s true that different points of view may end up leaving you a little confused , because it's hard to sort out what's right. Still, it's better to be confused because you know a lot, rather than make the wrong decision because you don't know any better. This ignorance can come back to haunt you afterwards !

Also, if a doctor says I think you should do surgery , one of the first questions you should ask him is - Can you give me good reasons as to why I should not do the surgery ! A good doctor will understand your question , and will answer this appropriately . He will be able to explain the pros and cons ; share his biases ; and will be able to justify his advise. Unfortunately, there will be some doctors who will get affronted and upset about the fact that you are challenging their authority .

If your doctor gets angry because you ask questions, this just means that the doctors not very confident about his opinion - and you're actually be better off finding another doctor can give you a more thoughtful, rational , and well reasoned opinion , which you can be comfortable . If you find you are scared to ask your doctor questions , this means that something wrong with your relationship with him – and you need to fix this before matters gets worse. If the doctors makes you feel uncomfortable when you ask questions, this means the chemistry between you and the doctor is not right, and you’d be better off finding someone else . A good doctor values a patient’s questions , and will do his best to answer them respectfully !

Bad doctors and worse patients

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 20 May 2013 02:30:00 +0000

Patients enjoy complaining about doctors . Favourite complaints include:

how long they make them wait;

how much money they charge;

how many tests they order ;

how little time they spend;

and

how they never explain anything.

This is particularly true when the medical treatment does not go as planned. This is why when an IVF cycle fails , patients have a lot of complaints about their IVF doctor . No doubt some of these complaints are justified - but not all of them are !

When a patient who has failed an IVF cycle comes to me for a second opinion, the first thing I ask is - you please show me photos of your embryos. The standard response is a blank look, followed by - I didn't even know that you could ask for photos of your embryos ! When I reprimand them for not being better informed , they start getting defensive.“ I am not a doctor, so how am I supposed to know that you can take photos of embryos ! “

“ My doctor never gave me any, so what can I do ? “ When I ask why they did not do their homework before starting the IVF cycle, so they would know how critically important photos of the embryos are, because they document the quality of the IVF treatment , the response is – “ Isn’t that the doctor’s job ?”

Patients think I am criticizing them – and they start justifying their lack of information . When I question them , I'm not trying to be critical ; and I am definitely not trying to badmouth the earlier doctor; or make the patient feel bad about what happened in the past. I am simply trying to galvanise them into being more proactive, so that start to take more responsibility for the quality of care they receive ! Patients simply cannot afford to leave everything up to the doctor – they need to do their homework

proactively , before going for treatment.

During one of these Q and A sessions which I had with a patient recently , she got increasingly upset and frustrated . I went to a doctor because he was highly recommended , and I blindly obeyed everything he told me ! This doctor had a great bedside manner; and she trusted him. If he does not give photos to this patients , what do you expect me as a patient to do about this ? How can I question him ? Won’t he get upset because he thinks I am challenging his competence ? The patient then started blaming the doctor for not providing the photos.

Yes, it's true that any IVF doctor who does not proactively and routinely provide photos of the embryos to his patients is a bad IVF doctor . However, a patient who doesn't insist on photos of her embryos is an even worse patient – and perhaps deserves to get a bad doctor !

It’s fine for patients to make a mistake once – but if the patient keeps on going back to the same doctor and not insisting on photos , I think this reflects badly on the patient . After all, IVF is not a monopoly – there are lots of IVF doctors, and patients can take the time and trouble to find a better IVF doctor.

If you stop to think about it, it’s naïve to expect doctors to improve. After all , it's not always in their best interest to share information . While some are transparent and will provide photographs of embryos , many prefer taking advantage of the information asymmetry, so their authority as the “expert” is not challenged !

However, it’s definitely in the patient's best interest to ask for photos – and I am not willing to be charitable and forgive patients who refuse to take the time and effort to be proactive. There is a lot at stake when you are doing an IVF treatment – and it’s your duty and responsibility to be well-informed !

There’s no need to be aggressive , but you need to learn to be assertive. And if your doctor takes offense, this is a red flag – and you should start searching for a second opinion.

If patients don’t start doing this, this is going to be harmful - not only for patients , but for good IVF doctors as well. If the cycle fails, and the patient learns that key information was not shared with them, she will start losing confidence in all IVF doctors , as a result of which the image of all IVF doctors takes a beating.

Success story for a man with globozoospermia

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 13 May 2013 02:00:00 +0000

As a referral IVF clinic , we treat many patients who have failed IVF and ICSI cycles in other clinics. Here's a success story from such a couple.

Globozoospermia is a very rare condition , and most IVF clinics in the world will not be able to even properly diagnose this condition, leave alone manage such complex cases. While I am very proud of the fact that we helped our patient to achieve a pregnancy, I am even more proud of the fact that he has become an expert patient, who is very well-informed about his problem ! He now knows more about globozoospermia than most IVF specialists !

Here's his first person account.

We got married in August 2009, and after marriage we were very happy and enjoying our new phase of life. After one year we thought of next stage of life - parenthood , which is very precious in every couple’s life. But our planning didn’t work. Then we approached the doctor. At that time we were in Kuwait we went to a famous clinic of Kuwait. The doctor suggested for complete diagnosis. The diagnosis resulted in identifying the reason for infertility is due to quality of sperm .However doctor said we can go for IUI treatment , and because of our lack of knowledge about infertility treatment , we underwent 2 cycles of IUI treatment in first half of 2011 with no success.

In June 2011, we shifted to UAE and the first thing we hunted for was the best infertility clinic in UAE .We took all our earlier reports and explained everything about our problem and the treatments that we had undergone previously. Then doctor suggested for a repeat of semen test and the results shocked me . All my previous reports showed semen counts of 30 million and suddenly semen results showed just 3 million with less than 5% motility with 98% abnormal morphology. He suggested us to go for an ICSI cycle. We went for our first cycle of ICSI in UAE in November 2011. 2 eggs were fertilized .However the doctor mentioned the quality of embryos was not good and the growth was very slow , possibly because of slow sperms. We waited for 14 days and did the HCG test , but the result was negative. Then we were frustrated and we decided to take a break . I decided to try to improve quality of sperm and went through a nine months course of homeopathic treatment.

After ten months of treatment we went for a sperm analysis at SRL diagnostics Dubai. The lab analysis showed an improvement in sperm count and motility but reported a new term - 80% Globozoospermia (which means the acrosome or cap on the head of my sperm was missing).

Then one day I searched for the best clinic in India who can give us new hope. We found out about Dr Malpani. We mailed him all the details and the treatments that we have undergone in the last two years. He responded almost immediately to my mail, and I was very happy. Then in my next mail I asked him for an appointment.

We planned for our first cycle of ICSI @ Malpani clinic in October 2012. In our first meeting with Doctor , he asked us what our Plan B was ( if treatment is not successful ).We were surprised and bit confused but later understood the importance of having plan B when he explained this to us. He educated us about our problem. Our ICSI cycle was not successful and none of the eggs got fertilized. Dr called us to the clinic and embryologist showed us the eggs and the video of complete process of ICSI. I was told this is not normal and that globozoospermia was a very rare diagnosis. It was suggested I repeat the semen test with special stains for checking the presence of acrosomes on the sperm @ Dr.Avinash Phalkde, SRL Diagnostics , Shivaji Park.

I was diagnosed with 98% Globozoospermia. Dr said I was the first patient he had come across with this diagnosis. He emailed me a few research articles on Globozoospermia and the articles mentioned that lack of acrosome can cause complete fertilization failure after ICSI . There were very few success stories in the world for treatment of globozoospermia. Then we decided to go for plan B (donor sperm) and met Dr in Feb 2013. At this time, Dr explained the option of doing ICSI with about Assisted Oocyte activation using a calcium ionophore . He told us that they would be doing it for the first time in their clinic . We took few days time to make up our mind and then decided to go with the treatment.

We had our 2nd ICSI cycle @ Malpani clinic in March 2013 but this time with AOA with Calcium Ionophore. This time 2 of 8 eggs got fertilized and the quality of embryos was very good. And after 14 days of waiting time it was a great feeling, because the pregnancy test was positive. We had our first scan after 7 weeks of pregnancy and we have a bonus because it is a twin Pregnancy.

All kudos and all credits to Dr Malpani for suggesting AOA with Calcium Ionophore. We thank Dr Malpani from the bottom of our heart.

Internet reviews about doctors: threat or opportunity?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sun, 12 May 2013 10:40:00 +0000

This is an article which I wrote for the Indian Journal of Medical Ethics. This was a comment on the paper, Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899

For most doctors (though perhaps not for the readers of this journal), the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

The introduction of the Internet has already changed the way most of us find information, make phone calls overseas, keep up with the news, stay in contact with our friends, book airline tickets, etc. It has already had a major impact on the doctor-patient relationship in the United States, and it is just a matter of time before it plays an equally important role in the lives of Indian doctors and patients. While the technology has many benefits, it creates conflicts as well, because it gives patients a much bigger say in their own medical care – a concept most doctors feel threatened by, because it is so unfamiliar and new. One of the controversial areas is the sprouting of physician rating sites, which allow patients to rate, comment on, and discuss doctors' performance online, visible to everyone. This can be a mixed blessing, especially when patients are not happy with their doctors and use these rating sites as a platform to vent their frustrations.

This is a timely paper, because there are now many physician rating sites. Some have been created by private agencies, while others have the blessings of government organisations and health insurance companies. Although these have attracted a lot of attention from patients as well as the popular press, there has been very little discussion about these sites in medical journals, even though they are likely to have a significant impact on the way we practise medicine. While government and health insurance company representatives are vocal in their support for these sites because they believe they encourage transparency, many physician representatives argue against them because they are worried that they could compromise physicians.
This paper purports to have two aims. First, it offers a structural framework which can be used to debate the ethical principles behind these sites, thus providing a useful starting point for further decision-making and discussion: what should physicians and policy decision-makers take into account when discussing the sites and their impact on the doctor-patient relationship?

Because there is very little direct evidence of the harms and benefits of these sites, this paper also discusses how evidence from the related area of public reporting of physician performance can help to guide research in this new field.

The paper uses the three basic ethical principles of patient (and physician) welfare, patient autonomy and social justice.

In theory, the availability of information about the quality and competence of physicians (as assessed subjectively by their patients) can help patients stay away from bad doctors, thus helping them to get better medical care and enhancing patient welfare. The provision of online doctors' report cards encourages transparency of medical performance, and this could also result in greater public trust in the healthcare system.

While discussing the principle of welfare, the authors remind us that we also need to consider the impact of these sites on physicians' well-being. While the majority of reviews of these sites appear to be positive, negative reviews can cause both psychological and financial harm to the doctors concerned.
Physician rating sites also encourage patient autonomy, because they empower patients with information. The authors look at this benefit through the interesting prism of improving the patient's health literacy at three different levels: functional, interactive and critical.

As regards the third principle of social justice, the fact that these sites are online means that only patients with access to the Internet can use these services. This means they can actually worsen the digital divide between the haves and have-nots.

The most interesting question these sites raise is: do they provide reliable and useful information? Or is it possible to game these sites, as a result of which the ratings can no longer be trusted? Can doctors manipulate them by requesting their happy patients to provide positive reviews? Or can disgruntled patients ruin a doctor's online digital reputation by posting negative, biased and dishonest reviews about him/her on multiple sites? How can patients trust the information that these rating sites provide? And what can doctors do when they encounter negative ratings which they feel are unfair and biased?

The most useful nugget of information I found in this paper is tucked away in a table, which describes the five basic conditions which need to be met in order for a physician rating site to be useful. These include: transparency, justification, participation, minimum conflicts of interest, and openness to revision. Most sites have not been able to meet these conditions. Indeed, there is a lot of scope for improvement in how these sites are created and maintained, and paying attention to these basic principles will help to ensure that the next generation of physician rating sites provides value for all stakeholders in the healthcare ecosystem.
I enjoyed reading this paper because it discusses an issue which is very close to my heart. However, I feel the author has done his readers a disservice by unnecessarily complicating the issue. He has used a rather formal, heavy style so that making sense of the article is an uphill task. Just because this article is written for an academic journal does not mean it should be hard to understand. Perhaps the fact that the author is from a non-English speaking country may explain why the language is not lucid.

After reading this article I encourage physician readers to google their own names to see what their patients are saying about them. It is going to be increasingly important for doctors to manage their online digital reputation, because whether we like it or not, our patients are going to talk about us. We must learn what our patients feel about us. Ignorance is not bliss; in fact it can actually be harmful.

Patients have always had opinions about their doctors; after all, this is how a doctor's reputation develops. Traditionally, this was by word of mouth, a slow process, and it could take a doctor a lifetime to build a reputation. Physician rating sites have accelerated this process dramatically. However, while many patients will swear by their doctor, there will be others who will swear at them.

While it is all very well to take the moral high ground when talking about the right of patients to freely express their opinion about a doctor, I can vouch from personal experience for the fact that negative reviews can raise one's hackles quickly. While some such reviews may be well-deserved, others are unfair because they have obviously been penned by disgruntled patients, venting their bile. Others may even be planted by the competition.

Can we censor these sites? Let us not fool ourselves; the horse has left the stable. It is a fact that we will need to learn to live with patient complaints – including the ones posted online on doctor rating sites, for all to see.

The good news is that these doctor rating sites can actually help doctors to become more patient-centric. Hopefully, we will start treating our patients better, because we know they can harm our reputation by going online and posting negative reviews. Doctors should read the patient feedback stories at doctor rating sites to educate themselves as to what patients want from their doctors. The good news is that what patients want from their physicians is not all that different from what good physicians want to offer their patients. Patients are generally not unreasonable, high-maintenance consumers; they simply want doctors who care, listen, and know what they are doing. By reading the positive ratings, doctors will have role models of good physicians to emulate, and by reading the negative ratings, they will learn what to avoid. Smart people learn from the mistakes of others, and we can learn a lot about what a medical encounter feels like from the patient's perspective by browsing through these websites. They will help us become more empathetic doctors if we are mature enough not to take the negative ratings too personally.

In the big picture, these rating sites are a great opportunity for the medical profession to be open and transparent with patients. Medical associations should set up doctor rating sites to ensure that the basic information which patients need about a doctor (clinic location, credentials, professional qualifications and so on) is available. Also, these sites will be comprehensive because they will provide information on all doctors. If these are seen to be fair and frank, patients will be happy to refer to them as an authoritative source of information on doctors, rather than waste hours scouring dozens of unreliable and incomplete sites. It is also a good way of identifying the bad eggs in our profession, those who end up giving all of us a bad name. Even though we know who these are, we often prefer to participate in a conspiracy of silence and to turn a blind eye to their antics. Rating systems will allow the truth to come out in the open more quickly, helping with self-regulation of the profession. The Medical Council could take cognisance of repeated complaints about a doctor, and take action to prevent problems from flaring up.