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Many doctors are still worried that it's unethical to have a personal website.They feel that this amounts to advertising, and that a website is a way of soliciting patients.

I strongly disagree. In fact, I feel it's unethical for a doctor not to have their own website ! The word doctor is derived from the word, " docere", which means to teach. This clearly means that one of the key responsibilities of a doctor is to teach their patients. While many doctors do this face to face, the amount of teaching which can be done this way is very limited - and a conversation is not the best way of transmitting information.

Doctors who publish their own websites communicate with their patients online - and a website is a much more powerful tool of reaching out to thousands of people who are looking for information ! If the doctor wants to be sure his website is popular and gets lots of traffic, he needs to provide information on his website which is of value to patients, which means his website has to be full of patient educational content . Good doctor's websites are not all about the doctor - they are all about the patient !

A website allows a doctor to provide authentic , reliable updated information to patients. This information is local - and can be provided in the regional language ! Since it's provided by a trusted figure, patients are much more likely to trust this information.

Doctor's websites are a great way of reducing medical myths and misconceptions; and educating society at large !

Equally importantly, having a website forces a doctor to be transparent and honest. He cannot tell a lie on his website, as this will get him into serious trouble. This is good for patients - and doctors as well ! It also teaches the doctor to be much more patient-centric as he has to use simple words which his patients can understand when talking to them online !

If I were the Health Minister of India, the first thing I would do would be to make sure every doctor had their own website. This would create a win-win situation, which would help both doctors and patients !

There's a lot doctors can learn from other professionals - and there's a lot doctors can teach others as well !

An interesting "recent" innovation in economics is the introduction of "controlled trials" to determine the true impact of interventions to help alleviate poverty. Common sense would suggest that giving the poor loans will them help to turn around their lives - but in reality, this is not what usually happens. The road to hell is paved with good intentions, and "aid" can often end up killing initiative ; fueling waste and corruption; and breeding dependence ! Handouts don't always work well - and it's easy to waste a lot of money very quickly ! The only way to find out what works and what does not work is to perform experiments in the field - something which doctors are very good at ! Innovations are a part and parcel of medicine - but which ones are really useful ? And which ones aren't ? Doctors are very good at figuring this out because they've been doing this for so many years - and the staple technique we use to do so is called a controlled clinical trial. Economists are now adding these to their armamentarium to judge how valuable field interventions are , so they have data to analyse impacts, rather than just having to depend upon their intuition !

Interestingly, marketeers do this all the time as well. They need to figure out which ads work; which don't; and which provide the most bang for their buck. In marketing, a randomised trial is called split A/B testing !

There's always a lot of anxiety when you have to go a doctor - and this is especially true when you have to do your tests to find out if you are fertile or not.

When your test results come back as abnormal, this is often your like your worst nightmare coming true ! The first response is often one of disbelief - maybe the lab mixed up my sample ?

Then start the mind games ! Oh God - does this mean I will never be able to have a baby ? Will we ever be able to fix this problem ? Will my spouse leave me if I cannot have a baby ?

Rule number one - please do not panic ! Remember that every problem has a solution - even if it may not be a very palatable one initially !

Please look at the silver lining - you are actually better off , because now at least we know what the problem is . The known enemy can be better than the unknown, because we can not focus our energies on bypassing the problem and finding a solution , rather than just groping blindly in the dark !

Also, remember that not every abnormality is clinically important. Many doctors will uncritically ask for a huge battery of tests for every couple to comes to them. Ironically, some patients are impressed by such a long ( and expensive !) testing protocol - wow - this doctor is very thorough ! He's doing so many more tests than the other guy did - which means he must be much better informed and more knowledgeable !

However, many of these so-called abnormal results are just normal variants, which are of no clinical importance. They are often found in normal healthy fertile couples as well ! They are just red herrings, which do not need any treatment at all ! Examples include: small ovarian cysts; small intramural fibroids and a positive TB PCR on endometrial biopsy. However, because doctors are so focussed on looking for problems, every time they come across an abnormality, their knee jerk reflex is to start treatment ! Sadly, many patients are also quite happy when the doctor "finds" an abnormality ! Aah - this guy is good ! He's finally found what the problem is ( which the earlier doctors missed because of their incompetence) - and now that he can treat it, I'll finally get pregnant !

However, often overtesting just leads to overtreatment - and to add insult to injury - the wrong treatment, because the doctor is "treating" a "problem" which has no effect on your fertility at all. Patients often end up wasting a lot of time and money - and then lose confidence in doctors - and in themselves ! They refuse to take the right treatment, because they've wasted so much on energy and money on the wrong treatment.

Also, this overtreatment can be dangerous and can actually reduce your fertility ! For example , unnecessary laparoscopic surgery to "treat" a small chocolate cyst can actually harm you, as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

Use your common sense - and it's always a good idea to repeat the test before jumping to the wrong conclusion ! Meanwhile, do your homework and learn more about the test; what its variations are - and what they mean.

If you are having a hard time making sure you are on the right track, please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm , and I'll be happy to guide you !

For many IVF clinics, the patients which cause the most distress are the ones who are poor ovarian responders. These are patients who have poor ovarian reserve - and are often heartsink patients, because no matter what we do , it's very difficult to get them pregnant !

It is possible to get them to grow eggs and make embryos - and this actually makes the matter even more complex. This often creates false hopes - if I can make eggs and embryos, of course I can get pregnant ! All I need to do is to get the embryo to stick !

Unfortunately, there is no easy answer, and every patient needs to look into their own heart to resolve this personal quandary for themselves. While we are very happy to aggressively superovulate these patients, I feel using expensive and unproven treatments ( such as growth hormone injections , intravenous immunoglobulins and IV intralipds ) are difficult to justify !

What makes a complex situation even more confusing are the anecdotal success stories which litter the internet ! It's hard to separate the wheat from the chaff, and since hope springs eternal in the human breast, many patients are willing to "give it one more shot " !

From a medical point of view, using donor eggs is the most efficient way of solving the problem - with a very high success rate. Unfortunately, it's also the one solution which is hardest to come to terms with ! The question you need to ask yourself is simple - what's most important for me ? Do I want to propagate my own genes ? Or do I want to have a baby ?

Need help in making a decision ? Send me your medical details by filling in the free second opinion form and I'll be happy to guide you through your options, so you can make the best decision.

" Keep people in touch and involved in times of need with our secure, confidential and FREE online service here at justvisiting.com - the sharing network for caring people.

There's no catch, we're a not-for-profit organisation committed to helping you share the responsibility of caring for a loved one with your friends and family."

This is such a clever idea ! Every hospital should offer this service to its patients !

This is a guest post by Dr. Sai, Senior Embryologist at Malpani Infertility Clinic

The collection of testicular sperm directly from the testes allows us to help men with azoospermia to have a baby with their own sperm ! This is called testicular sperm extraction with ICSI ( TESE-ICSI ). It’s easy to find sperm in men with obstructive azospermia, because their testes produce sperm normally. However, it can be very challenging to find sperm in men with non-obstructive azoospermia who have partial testicular failure, because sperm production in these men is very patchy.

When doing a testicular biopsy, there is sometimes some bleeding, and often the testicular tissue which the surgeon hands over to the lab is blood stained. When these samples are processed in the lab to recover the testicular sperm, it’s extremely difficult to identify viable sperms , because the RBCs obscure the field completely.

This is the protocol I use for processing testicular tissue for TESA at our centre .

• Dissect the tubules with sterile tuberculin syringes. This allows me to separate the testicular tissue tubule wall from its content. I discard the content, and collect the content in a sterile 15cc centrifuge tube.
• Centrifuge the content at 1200 rpm at 5 min.
• Draw off the supernatant (discard)
• Resuspend the pellet in 1 ml of room temperature RBC Lysis Buffer solution. This contains 8.3 g/L Ammonium Chloride in 0.01M Tris-HCL Buffer (pH of 7.5 + 0.2)
• After 5 minutes, add 2 ml of room temperature sperm preparation medium.
• Mix it gently and centrifuge at 1200 rpm for 5 min.
• Draw off the supernatant.
• Resuspend the pellet in 0.2 ml room temperature sperm preparation medium.

After processing , I place microdrops of the washed testicular tissue content on the ICSI dish , which is layered with culture oil. I then scan the sperm selection drop, and use the injection pipette to pick up the testicular sperm from the prep and move it to a PVP drop until injection.

There can be a lot of debris in the testicular homogenate ( precursor or immature sperm cells ) . Therefore it requires a lots of patience to process this tissue. I repeat this process until I have enough sperm to inject the eggs with, plus a few extra for spares.

Here’s a case study of a very challenging patient we treated recently. He had non-obstructive azoospermia, with small testes ( volume of 6 ml); and a FSH level of 18.2 mIU/ml.

During the treatment cycle, our andrologist, Dr Vijay Kulkarni, took 6 microbiopsies from each testes on the day of egg collection. Because the tissue was blood stained, it was very difficult to identify the sperm. This is why the tissue suspension was treated with RBC Lysis Buffer as per the protocol mentioned above, to remove the RBCs.

This improved visibility dramatically, and it now became possible to identify a few testicular sperm. In the picture below, you can see the injection pipette picking up a single sperm. Note that the background is full of other testicular cells, which emphasizes the fact that finding testicular sperm requires a lot of expertise and patience ! Also note that there are very few RBCs ( the circular cells with a central halo) in this field.



It took me almost 2 hours to collect enough sperm. Since the RBCs had been cleared, identifying sperm was possible, making my task much easier ! However, the majority of sperms appeared abnormal. They had a cytoplasmic droplet, amorphous head or stumped tail, and none of them were motile.

3 hours later, 24 eggs were collected from the wife, of which 20 eggs were mature ( metaphase II) . All 20 eggs were injected, each with a single spermatozoon immobilized by stroking the tail.

After overnight culture, 11 oocytes showed two pronuclei and five 8-Cell and 6-Cell embryos (Grade B and Grade C) were transferred into the uterus on day 3.

The patient conceived in this cycle, and this pregnancy is presently progressing well.

There is a reason doctors and nurses are called "caregivers" and it's been proven time and time again that when putting patients in a caring, positive environment, healing time is decreased significantly as opposed to a sterile, strict atmosphere where doctors and nurses exude arrogance and are insulted when questioned.


Family Matters

Last year, as I sat in the hospital with my mom who was very sick with cancer and couldn't take care of herself, for the sixteenth time waiting to see which type of nurse and doctor we were going to get: Jekyll or Hyde, I realized how nervous I had become when it came to who was going to really take care of the most beloved person in my life. I wanted the best for this wonderful person and knew she deserved the best, but I had become extremely defensive each time we went to the hospital due to the spectrum of health care personalities we had experienced. Not wanting to over step my boundaries with a dozen questions about why and what the staff would do to help my sick mother, but I struggled with the fact that she needed treatment physically, but also emotionally and when we were blessed with a friendly nurse and doctor that went a little out of their way to show that they cared, we held onto them with both hands as they led our terrified family in what we trusted was the right direction.


Life and Death

I've heard several horror stories about arrogant doctors who got a little too cocky and make mistakes that could have killed their patient due to their overconfidence. These types of mistakes happen more frequently than most people realize but are overlooked or covered up. So question your doctor or nurse, don't be afraid to stand up for your rights as patients, after all, it's your body and if you are uncomfortable, find someone else. It's hard enough to go through a painful time or watch someone who is sick and needs help, but trusting your care giver and feeling confident that they are also looking out for the one you care about or your best interest is imperative in the healing process both physically and mentally.


This is a guest post from Alexis Bonari , who is a freelance writer and blog junkie. She is currently a resident blogger at onlinedegrees.org, researching areas of online universities. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.

We all know that prevention is better than cure, and this is one of the reasons that executive health checkups have become so popular. They promise to help your doctor to pickup medical problems early , so they can be treated more effectively.

Unfortunately, even though the logic is very appealing, the sad truth is that in real life, health checkups are good for hospitals and diagnostic centers, but not for patients ! In fact, most doctors never do a health checkup for themselves , because they know how useless they are !

So what is your doctor not telling you ?

Let's look at why hospitals promote health checkups so aggressively. The checkup is great way of converting well people into patients; and creates a constant stream of customers for the healthcare system.

How ?

It's a mathematical certainty that if you run a sufficient number of tests , you are bound to find abnormalities. Once you find an abnormality, then the person is snared into the healthcare system, and the vicious cycle starts.

Abnormality = more tests = more consultations = more treatment - more surgery, often unnecessary

Let's consider a 40 year old asymptomatic woman who goes for a deluxe super-duper health checkup at a local 5-star hospital. Because she has opted for the Platinum scheme, the doctors does a vaginal ultrasound scan to check her uterus. She finds a 4 cm fibroid and then advises the patient to undergo surgery to remove it. Since most patients are ( understandably !) reluctant to undergo surgery, the soft-sell is that this is going to be " minimally invasive" surgery done through a laparoscope, so that there is no cut and this can be done on a day-care basis. Also, the insurance will pick up the tab !

It's very common to do this for ovarian cysts as well. Cysts are very common in women; and most are functional and will resolve on their own. However , the doctor scares the patient into doing surgery, using a number of fear-inducing techniques, such as : it may increase in size; it
may burst; or, it may become cancerous. The sonographer is also a part of this scam, and magnifies the findings by highlighting them and by reporting the size in mm, instead of cm ( a 4 cm cyst is reported as a 40 mm cyst , to make it seem bigger !)

The truth is that you cannot make an asymptomatic patient happier - and if she has no complaints to start with, she most probably does not need any intervention at all ! The right advise would be masterly inactivity. However, few doctors have the maturity to advise this.

In fact, they tell the patient that thanks to this checkup, they have picked up a problem which could have snow-balled in the future. The amazing thing is that patients are happy when an abnormality is picked up ( they can justify the money they spent on the health checkup !). Most patients are very pleased that the problem was spotted before it became a major issue.

The truth is that most of these so-called abnormalities are not really problems at all - they are just incidental red herrings discovered with modern medical technology, which the patient would have happily carried to her grave if she had been unaware of them.

All this overtesting is leading to an epidemic of overtreatment. Is this going to change ?

No - it will just become worse as time goes by. Thanks to better technology , it's becoming easier and cheaper to produce high quality images of practically any nook and corner of the human body. However, better pictures does not equal better clinical outcome. A lot of these images will pickup problems, which are just anatomical variants, but which will be "treated" by over-enthusiastic doctors. There is too much money at stake !

Also, remember that if an "abnormality" is detected, it requires a very courageous doctor to advise against treating it with surgery ! In reality, it's s much easier for the doctor to advise surgery and "fix" the problem. After all, if he does the surgery, no one will object ( whether the surgery was needed or not is never discussed). Find a problem - fix the problem, is a common knee jerk response. It's also much more profitable for him !

However , if he advises against surgery and the problem worsens over time ( as it will in a very small minority of patients), the patient is quite likely to sue the doctor for not taking care of it when it was first pointed out ! Even good doctors will advise surgery to protect themselves, even when they know in their heart of hearts that this surgery is not in the patient's best interests !

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I had just advised a young woman who had oopause ( poor ovarian reserve) to try empirical therapy, with DHEA, wheat germ , yoga and acupuncture , before we started her IVF treatment.

She wanted to know the rationale behind my advise. " Doctor, on one hand you are saying that I have poor ovarian reserve, which means that I only have few eggs left in my ovaries. Women are born with all the eggs they will ever have and I cannot make any new eggs any more. In that case, how will taking all these medicines help me to grow more eggs during my IVF cycle ? "

This was my reply.

" Yes, it is true that we cannot make you grow new eggs. Your ovary contains all the eggs you will ever have. These eggs are in a resting phase, and are contained in primordial follicles. Each month some of these these follicles are selected and start growing. This group is called a cohort, and this is a response to the high FSH levels during the follicular phase. Of these follicles , only one will mature, while the others will die ( a process called atresia). It is our hypothesis that yoga and acupuncture will help us to recruit more of your follicles , so that if the cohort is larger, hopefully more follicles will mature when we superovulate you during your IVF treatment."

I enjoy being a doctor because my patients keep me on my toes !

I just saw a young woman who was sobbing as if her heart would break. She had had irregular cycles for many years, and I had just informed her that the reason for her irregular cycles was the fact that her egg quality was very poor, and that the only way she could have a baby was by using donor eggs.

She was very upset - and was actually quite angry with me ! She had been going to a gynecologist for the last 3 years in order to try to have a baby. He had diagnosed her as having PCOD ( polycystic ovarian disease) and had told her that this was the reason for her irregular cycles. She was given Duphaston every month to induce a cycle - and had even had 2 IUI cycles done.

On reviewing her records, I pointed out to her that her FSH level on more than 2 occasions had been very high - and this confirmed the diagnosis of ovarian failure.

Now she was angry with her gynecologist ! Why hadn't he made the right diagnosis ?
How could he miss the significance of the high FSH level ?

It was not until she came to me for a second opinion did she realise that her high FSH meant she had entered the oopause. She was very bitter, because she had always been very worried about her irregular cycles. However, her gynec had always reassured her, saying - " Don't worry - you are young ! Your eggs are fine !"

It's important to differentiate between calendar age and ovarian age - and not all young women will have young ovaries ! Unfortunately, for many of these women, the diagnosis is not made in time. The eye only sees what the mind knows, and many gynecs do not even consider the possibility of premature ovarian failure when treating young women, because the majority of their patients are fertile !

It's even worse when they are misdiagnosed as having PCOD. The reason her periods were irregular is because she did not ovulate. This is called anovulation. Now while it is true that the commonest cause for anovulation is PCOD, the other common diagnosis which needs to be ruled out is premature ovarian failure. The high FSH level should have allowed the gynec to make the right diagnosis !

When patients have irregular periods, we advise them to do the following tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of their eggs).

Patients with PCOD have high AMH levels; high LH levels; and a normal FSH levels. Patients with ovarian failure, on the other hand, have high FSH levels and low AMH levels.

This diagnosis can be confirmed by doing a vaginal ultrasound scan which checks for ovarian volume and antral follicle count. Patients with PCOD have large ovaries, with an increased antral follicle count. Patients in the oopause have small ovaries and a reduced antral follicle count.

The worst tragedy occurs when a patient with anovulation because of poor ovarian reserve is misdiagnosed as having PCOD. Some doctors will do an ovarian drilling for these patients - and this destruction of their normal ovarian tissue will cause them to have iatrogenic ( produced by a physician) premature ovarian failure !

Conversely, we also to see patients with PCOD who have done IVF and have been told by their doctors that they have poor ovarian reserve, because the doctor did not do a good job superovulating them ! It's a pleasure to treat these patients, because with the right superovulation, they have very high pregnancy rates !

If you are unsure of your diagnosis, the single most important test you can do is to check your AMH level. This is a reliable test - and makes it very easy to differentiate between PCOD and oopause !

After reading yet another article in a leading newspaper on how stem cells are helping paralysed patients to walk, I spoke to the journalist to ask him why they were continuing to misinform patients. The use of stem cells has been hyped so much, that most "clinical use" of stem cells in India now is an abuse. Private clinics have mushroomed all over the country, where cardiologists, neurologists and orthopedic surgeons have all jumped onto the stem cell bandwagon, claiming that these "miracle magic cells" cure everything from paraplegia to heart failure to arthritis. The sad truth is that while stem cells may hold a lot of promise, a lot of this is just that - promise. It takes a long time and a lot of effort to convert this promise into reality and both patients and doctors need to acknowledge this fact. By making such brazen , unsupported ( read false) claims, both doctors and journalists are doing a dis-service to patients, their profession, themselves and society.

Doctors are actually harming themsleves by over-promising and under-delivering. To grab their 15 minutes of attention, they concoct all kinds of rubbish - and it's still surprisingly easy to hoodwink unsophisticated reporters who are often medically naive. I can understand why doctors do this, however. Each media story gets them a fresh influx of new patients - and lots of moolah ! It's hard to say no to money and a newspaper story, so most doctors are quite happy to learn from the media stars; and since doctors are quite savvy, they employ PR agents to help get their name out in the press.

But why do journalists, who are supposed to be sophisticated professionals, whose expertise lies in reporting the truth, fall for this ?

Reporters have to live with deadlines and they are under constant pressure to report "news". Their editors pressurise them to dig up positive stories about Indian doctors, to offer a "feel-good" flavour to the reader. Stories about the cutting edge" of medical techology are always well-read - and will usually secure a by-line for the reporter. These are human interest stories, and are often featured prominently in the paper. Also, there is lots of competition amongst journalists for stories, and many of them are afraid to displease these media-savvy doctors, as some competitor may get the next scoop !

However, it's not just the journalists who are to blame ! They are not gullible, but they are not medical specialists either ! This reporter told me that when he asks other doctors for their opinion, so they can provide a balanced article as well as an alternative point of view ( something which is basic to all fair reporting), many doctors flatly refuse to criticise another doctor in the media. While they are extremely happy to bad mouth these doctors and backbite about them ( the amount of medical politics which goes on is mind-boggling !) , they do not have the courage of their convictions to say so aloud ! They refuse to "go on record" and refuse to stick their neck out in public. This is a shame. By refusing to criticise bad doctors, they are abdicating their responsibility and actually encouraging bad doctors to flourish. They are scared to be critical of other doctors because they do not want to break the bonds of professional collegiality. I think this is ridiculous. Ethical doctors - or those who think they are ethical - have a responsibility to be honest and to prevent medical malpractise. They need to acknowledge that the media has a very important role to play in educating the public - and that good doctors need to partner with the media, to ensure that medical stories and honest and factual. By keeping quiet, they are actually being cowardly ,unethical and dishonest. The fact that full-time professors in medical colleges refuse to be quoted is especially disheartening. These are academic professionals, to whom journalists should be able to turn to for an honest unbaised free and frank opinion , because they do not have an axe to grind. Unfortunately, even these leaders of the profession prefer to criticise journalists for carrying poor quality stories, instead of actively contributing to ensure that the stories are reliable and accurate ! They need to have the courage of their convictions , rather than just behave as docile impotent back-benchers.

If leading doctors will not accept responsibility for policing the medical profession and for keeping doctors honest , then they really should not complain about these poor quality stories ! If you are not part of the solution, this means you are part of the problem !