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An IVF cycle is full of uncertainty and suspense , like any other biological system. However, being prepared for these can help you cope better !

Think of an IVF cycle as being a series of hurdles - and you need to cross all these to reach the finish line ! While most patients will cross these hurdles with ease in a good IVF clinic, each of these is a " moment of truth ".

• You should grow many follicles
  
• These follicles should mature
• Your uterine lining should also mature in synch with your follicles
• Ovulation should not occur before the eggs can be collected
• Mature eggs must be retrieved by the doctor during the "pick-up"
• Your sperm must fertilize the eggs ( with IVF or ICSI)
• The embryos must divide and grow healthily in the IVF lab
• Your embryos should be transferred by the doctor smoothly into your uterus
• Your embryos should implant

Think of it as a series of hurdles, all of which have to be cleared , in order to win the race !

As you can see, how well you negotiate these hurdles will depend to some extent on your biology ( how good your ovarian reserve is , for example); while others will depend upon the skill of the doctor !

A good clinic will guide you through these moments of truth, and share information with you, so that you can rejoice when things are going well - and be prepared in case things do not go as planned. Unfortunately, as with any biological system, IVF is also full of ups and downs - and the more you know about what is happening - and what is going to happen next, the more easily you'll be able to go through your IVF treatment !

Infertile patients can be desperate for a diagnosis. They naively feel that once they know what the problem is, we'll be able to find the solution !

This leads to testing - which has now become an epidemic of overtesting.

Let's see why. Patients still have unrealistic expectations from IVF treatment. Doctors often do not bother to counsel them. They are so focused on "grabbing patients" to do one IVF cycle, that they overpromise success. They make tall claims during the IVF cycle to keep the patient's hopes high - everything is going very well- you will definitely get pregnant ! Then, when the cycle fails, the doctor becomes inaccessible ! Patients get disillusioned and hunt for a new doctor. The new doctor needs to do something more - something different - as compared to the old one - after all, he needs to show the patient he is better !

The new doctor will then order a whole panel of expensive new tests. Many of these are completely irrelevant and do not affect fertility or the IVF treatment, but patients are quite clueless and do not know any better. They are happy to do whatever the new ( and improved !) doctor suggests - after all, aren't more tests a sign that this new doctor is very thorough and competent ?

An excellent example of this is : PCR for TB testing in India; immune testing for killer cells in the US; and sperm DNA fragmentation tests.

All doctors know that if you do a lot of tests , it's a matter of statistical certainty that you will find an abnormality. Once this is found, this is considered to be the problem causing the infertility which then needs to be fixed ! The new doctor is triumphant ! See, the earlier doctor was incompetent and did not bother to test you properly which is why the cycle failed. Aren't you glad you came to me ? Now that I am treating you , this problem will be solved and you will get pregnant !

Patients are happy too ! They are impressed by how well-informed and thorough the new doctor is. In fact , is sometimes seems that the more the tests - and the more expensive they are, the happier the patient - and the happier the doctor !

This leads to a negative vicious cycle of overtesting and overtreatment. Doctors often end up "treating" red herrings. All this just wastes time and money - and then the new doctor fails, then
patients lose confidence in doctors - and in themselves !

Caveat emptor - do your homework before agreeing to do tests ! And always ask this simple question - How will this change my treatment ?

We deal with a number of difficult patients who have failed multiple IVF cycles elsewhere. Many of these are poor ovarian responders and a common question is - How many follicles do you need to go ahead with the treatment ? Is there a number in your clinic below which you will cancel the cycle ?

These patients suffer from a lot of anxiety and apprehension during the superovulation, because they know they are not likely to grow many eggs. They have already had many of their cycles cancelled in the past - and this can be quite a cruel thing to do , because these are eggs which they have produced with a lot of effort ! Their eggs are precious - and represent their best chance of their having a baby with their own genes. This is why when the doctor cancels the cycle because they have not produced enough eggs, their heart breaks.

From the doctor's point of view, cancelling the cycle seems to be a very rational thing to do . Why make the patient spend so much money when the chances of success are so slim ?

What they forget is that the patient knew prior to starting the cycle that the chances of success were slim, so that the fact that she has grown few eggs has not really changed anything. If she's prepared to take that slim chance it can be cruel to deprive her of it

It's especially cruel when the real reason doctors cancel the cycle is because of "clinic policy" - because they do not want to mess up their success rate statistics !

These are challenging patients, and during superovulation, the major worry is - Will we reach the stage of egg colleection ?

Many doctors will cancel cycles if there are less than 4 follicles, because poor responders have a lower success rate and they do not want to harm their clinic IVF succcess rate. These are league table games clinics play, where they weed out the difficult patients to artificially elevate their published succcess rate figures.

We need just one follicle to go ahead, as long as the patient has realistic expectations and understands that there are still many more hurdles to be crossed after egg collection: there may be no egg; or the egg maybe immature; or it may not fertilise. We can be aggressive and are happy to do our best to help the patient to have a baby, but sometimes biology can be cruel !

With this approach , our patients have peace of mind they did their best ; that they explored all possible medical options and did not leave any stone unturned. With this approach, it's often easier for them to move on to Plan B ( adoption or donor eggs) because they know they've given it their best shot.

The outcome is always uncertain, and I do not want them to regret the fact that they did not try. We do our best to work with our patients - even if this brings down our success rates.

I want all my IVF patients to become an expert on IVF , which is why we spend a lot of time and energy in educating them; and in creating unique online educational tools to help them to learn more about IVF.

Now, I am not trying to teach my patients how to do IVF in their bedroom ! The reason we want them to know as much about their treatment as possible is because this is the best way of explaining to them why we are so good at what we do - and what makes us better than other IVF clinics . The outcome of any IVF treatment is always uncertain, and no matter how good I am , there is no certainty that the IVF cycle will be successful. Also, it's a very competitive field, and there are over 40 IVF clinics in Bombay itself ! Sadly, most patients are quite clueless, and do not have the ability to differentiate between a good IVF clinic and a bad IVF clinic.

If we actively involve patients in their IVF treatment, they are better able to understand what makes us one of the best IVF clinics in India. When they understand the science behind IVF, they appreciate all the time and effort we take in monitoring them and in personalising their treatment . We work hard in order to help our patients to have a baby, but only well-informed patients can truly appreciate all the effort which goes on behind the scenes !

Also, well-informed patients have realistic expectations from the IVF treatment . They understand that human reproduction is not an efficient enterprise and do not go to pieces when the IVF cycle fails.

Most IVF clinics are extremely stingy about providing patients with information about their medical treatment. They seem to take the approach that patients are stupid and will not be able to understand anything about their IVF treatment because it's very complex ! Some don't even bother to provide a treatment summary - while very few provide photographic documentation of the embryos.

We routinely provide our patients with photos of their embryos . Making embryos is the heart of what an IVF clinic does and we take pride in our work ! This is a tangible end point I can deliver and seeing high quality embryos reassures the patient that they have received high quality medical care - and this helps to build patient loyalty. Many will frame these photos and use them to start their baby's album !

Educating our patients is an investment in helping them to achieve peace of mind that they have received high quality medical care, so that no matter what the final outcome, they know that they have had their best possible chance at having a baby by taking treatment in our clinic !

I was watching TV late one night , into the wee hours of the morning…

I was so tired & bored that I started channel-surfing and I stopped on this program called “70&Pregnant” on the Discovery/TLC Cable Channel. Boy! Did it wake me up? Mark & I have tried for years to get pregnant and we realized about 15 years ago that because of my premature ovarian failure, only a donor egg would work for us. So needless to say when I saw this program, I perked up immediately…. On this program, they featured an Indian doctor who helped a 70 year old Indian lady get pregnant and have child with a donor egg. The donor came from a nearby Indian village & the cost was cheap by U.S.A. Standards for IVF.

During the program, the doctor discussed the cost of IVF in Indian and immediately, since fertility treatments for me & Mark are too expensive, when I heard the cost of IVF in India, I jumped up & started researching Doctors in India right then and there. I could barely sleep that night.

When I woke up the next day, I went straight to the Indian Embassy here in D.C. – no appointment, no announcement, nothing…. and just talked to whomever I could about the country. The receptionist was the sweetest and kindest lady in the world. She told me so much about the country, the time differential, how to dial abroad, etc. Then finally I asked, hey do you have a science or medical representative here from India as a part of your staff? She said yes and she directed me to the Counselor of Science for the Embassy. He happened to be free, praise God, so he & I chatted for about 20 minutes. I was so excited about the cost of IVF in India that I didn’t even beat around the bush. I told him exactly what I wanted and he poured out all the information he could. He bent over backwards to help me.

He told me, if you are going to India and you don’t know of a Dr. I’d recommend Dr. A. Malpani. I keep hearing their names and I’ve read extensively on them & their practice. I’m told they are the best in Mumbai. You can’t go wrong with them. They have a lot of good write-ups and in my field, this it he name that comes up when referring to IVF in India. This was a name he had in his memory. He didn’t have to ask anyone or call anyone. This made me feel really good because how many people have an IVF specialist’s name at the tip of their tongue just waiting for someone to come in and ask for it? Then he introduced me to the media and newspaper staff, I had tea, then walked around and met other staff who gave me DVDs, Maps, CDs, Newspapers, Hotel contacts, etc. I was even put on the Embassy’s newsletter’s mailing list for events. The folks at the Embassy were the most pleasant people in the world to deal with. They took all my concerns about traveling abroad to a country where I didn’t speak the language away instantly. They also told me that they would help me an in any way they could in the future.

So I went home, armed with all this good literature, DVDs, CDs, etc. and started researching on the internet and made contact with Dr. Malpani. This was in June 2010. I’ve asked Dr. Malpani questions weekly if not 2 and 3 times a week since June 2010 about IVF, donors, his/her practice, policies, procedures, etc. I’ve inquired about things on the internet, things I’ve heard, etc. and within a 24 hour period including Saturdays, Sundays and all holidays, Dr. Malpani’s answered my questions. I’ve even asked Dr. Malpani about questions that if I knew a little more about the internet I could have found on their web site, but Dr. Malpani, pleasantly & patiently answered them for me anyway.

While over the last 8 months of speaking with Dr. Malpani I’ve come to trust and value the practice, there was only one issue that held Mark and I up from flying to India and seeking IVF treatment immediately. We needed to find a donor that we could see & visually approve of 1st hand before the IVF procedure. Most doctors in India do not allow the recipient to see photos of the donors prior to the IVF treatment. Dr. Malpani’s practice is to match a donor to you and choose the donor anonymously. This didn’t sit well with me & Mark because while having a healthy donor is primary to us, it’s also important to us to see from whom ½ our baby’s identity will come.

After we told Dr. Malpani this, the option of advertising for our own donor was suggested. So we set out to find a donor by advertising in the local papers and on the internet. Dr. Malpani warned us to be patient, that it could take some time. So we placed ads in newspapers in India. We’ve even gone to Donor and Surrogacy Agencies and it’s been a world-wind experience.

We’ve spent about $2,500-$3,000 U.S. dollars on several newspapers, internet services and donor agencies just advertising and viewing photos. While we aren’t happy about the cost, we are delighted that we’ve seen the photos and chosen to see our donor. It’s renewed our resolve to see our donor no matter the cost or length of time it takes to find just the right one.

In the meantime, let me tell you what we’ve experienced while searching…Oh MY GOODNESS! We’ve had men tell us they could provide us with eggs. We had to explain (via email) so many times that men aren’t born with eggs that we just decided to come up with a “cut & paste reply” to all those emails from men that answered “Female Egg Donors ONLY please Advertisements”. Then during our 2nd newspaper, we had men tell us you really need sperm & not eggs, let us supply them. We’ve had people email us nasty comments about what they think of science and what we are doing. Of course we deleted these and moved on as if they were never sent. We’ve had husbands respond to the ads & lie to us about their wives ages only to have the wives tell the truth later when we indicated that official birth certificates and Indian govt identification would need to be submitted to verify the accuracy of the age of the donor. We’ve had people treat us like an ATM because they knew we were calling from the USA and quote astronomical prices that multi-billionaires wouldn’t pay for golden eggs. We’ve had people tell us since we weren’t Catholic they couldn’t supply eggs after they answered the newspaper advertisements. We’ve had husband tell their wives no after their wives answered the advertisement. We’ve had people play really high priced negotiation games with us until we realized that they might not finally give up the eggs or would possibly hold them hostage if we dealt with them. We’ve had people call us back weeks later asking to donate for our original offer, after they realized we never called them back to offer a higher price. We’ve had people offer us eggs if we could guarantee them a job and flight over to the USA. You name it, we’ve had it. Most of it has been funny because we are committed to not get frustrated but I’d be lying if I said it wasn’t getting old at times.

All of this had us thinking once or twice…do we really want to try to find our own donor? Do we really know what we are doing? Then we’d go back and look at some of the photos and say, yes, let’s keep plugging along. Then when we finally were so tired and ready to give up & take an emotional break, the most stunningly beautiful donor replied to our advertisement. She was nice, well educated and seemed to be quite stable. Once we discussed the process, she said oh no. So here we were thinking we landed a donor, only to be stressed out with her back & forth fear of medication-taking, injection phobias and overall paranoia about egg retrieval. While we understood her lack of knowledge about what was required, we were drained emotionally by the process of trying to explain to her what was expected. We also found ourselves perplexed as to why she’d answer an advertisement when she should have expected that at least 1 needle was involved somewhere along the process.

Eventually we told her that this was more stressful than we could endure and we declined to continue further. She came back and said she was willing to think about it again once she had verified the process with Dr. Malpani. So she eventually spoke to Dr. Malpani and finally bowed out one last time. I must admit, I didn’t do a good job of telling her about the medications. I was too honest and this was best something left up to a Dr. to explain because just listing them out is scary to someone who’s not seeking a child and just wants to help, even if it is for monetary gain. I should have thought about that before I blurted out all the medications and injections. I now know it’s best left to a trained physician to tell patients about stuff like that.

So in the end, Mark & I knew it wasn’t meant to be so we didn’t get too upset by her resurfacing only to bow out one more time. We believe what’s meant for us is meant for us and will come our way without a bunch of coaxing and cajoling.

So we continued to plug on. Then Dr. Malpani suggested egg sharing. We were elated with the option but then we ran into a road block when the only person who has offered to share her eggs wasn’t of Indian descent. This mattered greatly to us because of my heritage so we again, prayed about it, declined that egg sharing opportunity and are now moving forward.

So, 8 months later we are still looking for an Indian egg donor. We’ve put our IVF plans on hold until we either find one through an agency willing to allow us to pay them a referral fee and use their donor or until we locate a donor whose photo we approve of. Most practices aren’t interested in sub’ing their donors out so this may result in us going back to the newspapers for more advertising.

Mark and I’ve talked about this until we are blue in the face. It’s most important for us to have a healthy child. But it’s secondly (not equally) but still important to us to have a child that looks like me as much as possible or like she/he could have been related to someone in my family, even with ½ of my husband’s DNA injected in the mix. Because we’ve located two women who fit this bill but who bowed out because of (a) fear of the procedure to extract the eggs and the 2nd because of a family and medical emergency, we’ve decided to press on because we now know that in a country of over 5 Billion and in a city like Mumbai of 22 Million, she’s out there. We just have to be patient and allow God to deliver her to us.

Traci & Mark.

trbrown1@yahoo.com

Most men are very reluctant to get their sperm tested. For one, most men hate going to a doctor - and they need to be dragged to the clinic for any medical testing - whether it's a X-ray or a sperm test. Secondly, most men still believe that having a baby is their wife's job, so it's the wife who should get tested. For another, they expect that their sperm count must be fine , so why bother to get it tested ? " Hey - I can have sex as often as I want, and if my virility is fine, I am sure my fertility will be superb too ! Why waste time and money getting it tested ? " Finally, it can be quite humiliating to have to go to a lab to produce a semen sample - and this is an experience most men are quite happy to bypass.

The problem is much worse for men who know that they have a low sperm count. They are secretly petrified that their sperm count may drop even further , which is why they are so reluctant to get their semen re-tested ! ( They also know that if their sperm count is low, their spouse will nag them incessantly to stop smoking and stop drinking - and is having a baby really worth giving up all the pleasures of life for ? )

This reluctance on the part of the man is not something many wives understand - " I am the one who has to go through all the painful tests and shots , so why is he making such a big deal about getting his semen tested ? " Ironically, the wife is being amazingly unempathetic in this case. While it's true that it's usually men who are clueless, any wife who does not understand the heartburn an infertile man goes through when his sperm count come back as below normal is being remarkably obtuse and clueless. The secret fear many men with a low count have is that the sperm may keep on dropping until it goes to zero - and then what ? Men are masters as denial - and since most of them hate going to a doctor for any medical problem, it's quite understandable that they are not happy about allowing their vulnerability to be exposed to the whole wide world ! And while producing a semen sample is not as painful as doing a HSG, being forced to produce semen on demand in a dark, smelly bathroom when there are five other men waiting in line can be very unpleasant ! Even worse , if the man fails to get an erection and produce a sample when asked to, this can often be the last nail in the coffin of his self-confidence. He'd rather go and shoot himself than put himself through the humiliating ordeal once again.

Sadly, many doctors do not realise the enormous stress some infertile men go through when producing a semen sample - and this just contributes to the difficulty. Since most nurses in an IVF clinic are female, it's very hard for a man to talk about his personal problem to anyone ( the doctor's never available in any case !) And if he fails once, this often becomes a self-fulfilling prophesy, setting up a negative vicious cycle which is very hard to crack. Seeing his wife angry and upset just adds to the man's woes - and he'd rather just forget about having a baby rather than subjecting himself to the stressful exercise all over again !

My patient was at her wit's end and was sobbing her heart out. I have done 5 IVF cycles all over the world, Dr Malpani - and they've all failed. What do I do next ?

This is always a complex question - and there's no easy answer. You need to be analytical and logical, so we know what to do next. The trick is not to waste time looking for problems, but rather to focus on solutions which will allow us to bypass the problems !

We need to ask ourselves - what have we learned from these failures ? What can we do differently the next time ? What can we change to increase the chances of success ?


If you do need to change something, remember that there are only 5 things we can change in any IVF treatment

1. The IVF treatment protocol
2. The clinic
3. The sperm
4. The eggs
5. The uterus

Let's think through this process logically , so we can prepare a plan of action for the next cycle.
This is a very useful framework, which helps you to analyse the failure; learn from it; and then move on !

First, I need to emphasise that sometimes there's really no need to change anything at all. Not every IVF cycle is going to result in a baby, even it it's text book perfect. Sometimes, all you need is to be patient - and a little bit of luck !

But what if 3 cycles have failed ? Then what ? Let's look at what we can change, step by step.

1. The IVF Treatment protocol. While the IVF treatment protocol is pretty standard, every woman's body is different, and every patient responds differently to IVF medication ! Each cycle teaches us how your body responds to superovulation - and a lot of the art of IVF and the skill of a good IVF doctor consists of superovulating you with just the right dose of medications, to get you to produce an optimal number of high quality eggs. While most young patients with normal ovarian reserve grow well in response to a standard protocol, patients with poor ovarian reserve and those with PCOD need a lot of extra attention and closer monitoring. We may need to use additional alternative medicine supplements such as DHEA for these patients; while others may need higher doses of HMG. Some of this is trial and error - and you must keep careful records and learn from each cycle , until we can customise the perfect protocol for you !

2. The clinic. If you find your doctor is very rigid and is not willing to make any changes inspite of repeated failures, then it's a good idea to get a second opinion, to confirm you are on the right track. Getting a fresh brain to look at the problem can be very helpful and can offer new insights ! While the basics of IVF are the same all over the world, there is a great deal of difference in the quality of the services IVF clinics provide - and it's a good idea to keep an open mind and explore alternatives if you feel your present clinic is stuck in a rut; or refuses to do anything different. This is especially true if your doctor batches patients; does IVF on a part-time basis; refuses to share medical information with you; or does not provide you with photos of your embryos ! A word of warning here - doctor shopping is not usually a smart thing to do - and if you have a competent doctor with whom you have a good relationship, then it's best to preserve this, and ask him to offer additional options to you, rather than to establish a new relationship with a new doctor. However, when you do go from one IVF clinic to another, you are quite likely to get VIP care, because IVF doctors are quite competitive, and it's often a matter of pride for them to get a patient pregnant when the earlier IVF doctor has failed to do so !

3. The sperm. If you have failed fertilisation in an IVF cycle, then you need to do ICSI in your next cycle. This will ensure fertilisation and is a simple and effective solution ! Using ICSI allows us to work with practically any man's sperm, no matter how low the count or poor the motility and morphology . I do not believe DNA fragmentation affects success rates if ICSI is being used if the embryologist is competent ; and I believe that if we have poor quality embryos after ICSI even in men with severe oligoasthenospermia, the problem is usually because of the egg or the lab, and not because of the sperm. ( I know that many clinics will blame the poor sperm quality when they get poor quality embryos after ICSI. This is rubbish - it's usually just a poor quality lab which is to blame ! However, men with a low sperm count have low self-esteem - and they are quite willing to accept this flawed conclusion - and use donor sperm for the next cycle ! ) . It's possible that in a very very few men who have persistently poor embryos after ICSI, it could be the poor quality sperm which are responsible. The only way to prove this is by split crossover testing ( fertilising the wife's eggs with donor sperm; and fertilising donor eggs with the husband's sperm, and then comparing the embryo quality ), but as you can imagine, this can be very hard to do in real life !

4. The eggs. When you remember that the egg is a thousand times bigger than the sperm; and that the energy for cell division during embryo cleavage comes from the mitochondria in the egg's cytoplasm, it's hardly surprising that the vast majority of time embryos fail to implant is because of "egg problems". The problem is that it's very hard to make this diagnosis, as eggs are just spherical blobs, and we simply do not have the technology to assess egg quality or egg function. However, if there is a problem with embryo quality in a good IVF lab, 9 times out of 10 the problem is because of the eggs. While it's sometimes possible to correct this problem in the next cycle by using various measures to optimise egg quality ( such as DHEA or a more aggressive superovulation procotol), most of the time the most effective solution is to use donor eggs. This option has a very high success rate - but it can be quite hard for some women to accept - especially those who are young and have a good ovarian response, with a normal AMH level and a normal antral follicle count. It can be hard for them to come to terms with the possibility that their eggs may be flawed - and the idea of using foreign genetic material can be unpalatable to many women ( and their partners).

5. The uterus. Surrogacy has become very popular recently because of the disproportionate amount of media attention it attracts, and many women feel that the best medical solution for them after many failed IVF cycles is surrogacy. After all, the fact that the embryos are not implanting means the uterus must be " defective" , so doesn't it make sense to use a fertile woman's uterus as an incubator for 9 months ? However, the truth is that surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem. However, because it's very profitable to offer surrogacy , many IVF doctors are keen to push their patients towards this option . For a woman who has failed 5 IVF cycles and is fed up and frustrated, surrogacy does seem to be a very attractive option - no hassles with the dreaded 2 week wait - someone else can do all the hard work ! However, the success rate for surrogacy for these women is very poor, because it's not their uterus which was the problem ; which means that using another woman's normal uterus is not going to help at all !

I remind patients who have failed IVF to remember the Serenity Prayer -
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference. Outcomes are always uncertain, but if you take well-informed decisions on a logical basis, you will have peace of mind you did your best !

The failure of an IVF cycle always causes major heartburn. The next question is - Why did the IVF cycle fail ? What should I do next ? Did I get good quality medical care ? Or should I change my doctor ?

This is always a hard question to answer, because even if the quality of medical care provided is excellent, the IVF cycle can still fail. How is the patient to judge the quality of technical competence of the IVF clinic ? Did the cycle fail because the clinic was bad ? Or was it just bad luck ? You cannot rely on a doctor's bed side manner to judge his clinical skills - you need more tangible evidence - but what should you be looking for ?

Fortunately, the answer is very easy - you should ask for photos of your embryos ! The core competence of a good IVF clinic is to produce high quality embryos. Of course, whether these embryos will implant and become babies after they are transferred is not something which any doctor can control - but the quality of the embryos is a tangible end point which can easily be measured and compared.

I feel every patient should ask their IVF clinic for photos of their embryos - and most good IVF clinics will routinely provide these to their patients, even without being asked. Good clinics are proud of their skills - and are happy to show off the embryos they make in the IVF lab to their patients !

If your doctor refuses to give you a photo of your embryos, you should worry a lot ! What does he have to hide ? And why ?

And if you need help in making sense of your embryo quality, please email your embryo photos to me, and I'll be happy to help !

This is one of the commonest questions patients ask me. Doctor, I did an IVF cycle at this other clinic and it failed - can you please tell me why ?

Obviously, the next thing I need to do is to drill deeper to find out more details about the medical treatment provided, so I can provide an intelligent answer.

I ask patients for more details about their IVF cycle. What were the meds which were used for
superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? How many embryos were transferred ? What was the embryo quality ? What was the endometrial thickness ?

Most patients look completely blank when I ask them these basic questions - and some even think I am crazy for expecting them to know the answers. A standard reply is - Our doctor never told us anything !

Sadly, very few clinics in India provide patients with any medical details about their IVF treatment. Many of them do not even have the courtesy to provide a simple treatment summary - let alone details of the number of eggs collected or embryos transferred.

I have to spend a lot of time trying to reconstruct the IVF treatment provided with the help of scraps of prescriptions and ultrasound scans - and this can be a very frustrating exercise. While the fact that the clinic does not provide these basic details is a black mark against the clinic, I feel patients are also equally responsible . After the treatment is over, there's very little patients can do - and that is why I feel patients need to ensure that the clinic routinely provides all patients with all these details before they start the IVF treatment !

If I were an IVF patient, I would just ask the IVF doctor one simple question before starting the IVF cycle - Do you provide photos of embryos for all your IVF patients ? And if the answer is no, I'd find another IVF clinic !

The commonest question patients will ask before starting an IVF cycle is - what are my chances of getting pregnant ?

While it's true that the chances of success do depend upon how good your IVF clinic is, it's also true that the chances do depend upon biological factors which are outside your control - the most important one of which is your age !

You can now use the Free IVF Predictor to estimate how good your chances of success are ! While you cannot do much about your age, you can improve your chances of success by choosing a world class IVF clinic !

Most patients find that one of the most difficult things to manage during an IVF cycle is the dreaded 2 week wait ( 2ww) after the embryo transfer. Time seems to come to a halt and you live in a state of suspended animation - a bit like Schroedinger's cat ! Am I pregnant ? Am I not pregnant ? Every ache and twinge sends you scurrying to the bathroom to check if your periods have started - and you over-interpret every signal your body sends you. Am I feeling nauseous ? Is this a good sign ? Do my breasts feel fuller than usual ? Is this just PMS ? You try to prevent your mind from playing games with you, but this is surprisingly hard to do. Every hour seems to stretch on like a day ! You obsessively compare notes with all your online IVF friends - and drive your husband batty with your interpretations and wild imaginings ! Every time he drives the car through a pot-hole, you go bonkers with the anxiety that the jolt has jarred your embryos out of their safe uterine haven and caused them to fall out !

Why do I have to wait 12 days after the embryo transfer to do a pregnancy test ? Can't I do it earlier ? After all, if I am pregnant, won't the test show this ? Aren't the new tests very sensitive ? Aren't they supposed to show a positive result even before the period is missed ?

You cheat and start doing pregnancy tests anyways - how can it hurt ? And every time it's negative, you still hope against hope ! Maybe I did it too early ? Maybe it will show up as positive if I wait another 2 days ? How can God be so unfair ? After all the shots I have taken and the pain I have suffered, I am sure he will not let me down and will give me my baby !

Remember that your embryos are safe in your uterus and that nothing you do can harm them ! If they are going to implant, they will and there's precious little you can do to influence the inefficient biological process of embryo implantation either way.

Continue taking all your medicines; leading a normal life; and please remember the Serenity Prayer.

God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

We live in the US and I was diagnosed with Polycystic Ovarian Syndrome in 2003. We had been to an obgyn in the US and she had recommended 3 cycles of clomid treatment. Since this did not work for us, she had asked us to go for higher infertility treatments like Artificial Insemination or IVF. At that point we did not have proper information regarding these treatments and hence were not mentally prepared to proceed further.

Later we started research on the Internet regarding various infertility treatment options for us. It was at this time that we came across this amazing website. Dr.Malpani's website is an excellent source of information for infertility related issues. This was a panacea for all our questions. We then started interacting with Dr.Malpani through his website. We submitted the second opinion form with all the relevant information. Dr.Malpani graciously replied to all our queries. He was very prompt and patient with our questions. After 2 months of interaction with him, we finally decided that we should travel to Mumbai to start our infertility treatment at the Malpani clinic.

We stay at Hyderabad. However, Dr. Malpani was very flexible and had given us a treatment plan in advance so that we can plan out our trip and stay in Mumbai. We stayed at the accomodation at Janaki Nursing home. It was very cost effective and homely.

Our treatment started on Jan 7th 2010. We were advised to undergo IVF treatment. The IVF comic book on the website was very helpful to understand the various steps in the IVF treatment. On our first visit we were very impressed. There was not much waiting time. It was well organized and the staff was very friendly.

Dr.Mr& Mrs Aniruddha Malpani are well experienced and knowledgeable couple. Our treatment went exactly as planned per the steps in the IVF calendar on the website. It was on Jan 21st that 3 embryos were implanted. I requested for anesthesia during implantation since I was nervous. We were asked to see the embryos first. The embryologist walked us through the process of development before the implantation.

Later after 2 days of rest, we flew back to Hyderabad. I took a week's rest at home and flew to the US on Jan30 th. On Feb 4th, I did a home pregnancy test and by god's grace and Dr.Malpani's guidance and support I was pregnant. We were blessed with a healthy baby boy on Oct 1st 2010. What we once thought was very difficult turned out to be so easy at the Malpani clinic.

We would definitely recommend anyone looking for infertility treatment options to pursue treatment at Malpani infertility clinic.

One of the major worries most IVF patients have is about the competence of their IVF doctor. While most patients select an IVF clinic based on its reputation, the sad truth is that there is not much correlation with the actual quality of the medical treatment they receive and the brand name of the clinic. Many "big name" clinics are very impersonal and are run like assembly lines. The patient rarely gets to meet the doctor and most of the care is provided either by the nurses of the assistants. Patients feel they are helpless and passively put up with poor quality care, because they do not know what else they can do.

A much bigger problem is the lack of transparency and documentation . Most IVF clinics do not even bother to provide patients with a simple treatment summary ! Patients are clueless about basics, such as the number of follicles seen on the ultrasound scans; the number of eggs collected; the number of embryos formed ; and the quality of their embryos .

Patients are forced to blindly trust their doctor - and those who dare to ask questions are rudely put in their place !

What's worse is that it's well known that some IVF clinics will use your eggs ( without your permission) and gift them to someone else ! Not only is this plain unethical and wrong - it also significantly reduces your chances of getting pregnant !

How can you protect yourself ?

The answer is simple ! Ask questions - it's your body and your treatment ! You are paying a lot of money and you need the answers.

Please learn to ask intelligent questions ! Do your homework, so you do not have to bother the staff with basic questions to which you can find the answers yourself by going online. However, you need to find out details about your own treatment and how it is progressing. Ask for prints of your ultrasound scans and photos of your embryos. This is basic documentation, which every clinic should routinely provide !

If they do not answer your questions , this should be a red flag - beware ! A good doctor will share information - why should they hide anything ?

IVF treatment is too important for you to leave everything upto your doctor
you need to take an intelligent interest in your treatment. Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Not sure about what questions to ask ? Get a free second opinion at www.drmalpani.com !

Many patients are diagnosed with having unexplained infertility. This means that all their fertility tests - semen analysis; hormonal blood tests ( FSH,LH,PRL,TSH and AMH) for egg quality; HSG ( hysterosalpingogram) for tubal patency; and ultrasound scanning for ovulation monitoring are normal.

This can be a very frustrating diagnosis for patients. " But doctor, if everything is normal, then why aren't I getting pregnant ? " Patients are never happy with doctors who honestly answer - We do not know ! Patients expect a scientific definitive answer from their doctor who is meant to be an expert - and if a doctor cannot provide this, then be mustn't be very competent at his job is the natural conclusion many of them jump to . The truth is that our technology for identifying problems is still very crude. Thus , while we can check if the fallopian tubes are open or closed , we still cannot determine if the tubes are functioning properly or not. Similarly, while we can count the number of sperm in the lab and grade their motility, we still cannot find out if they are capable of fertilising an egg !

In actual fact, patients should be relieved that the diagnosis is one of unexplained infertility. This means that all their test results are normal; and that their basic reproductive apparatus ( eggs, sperms, tubes and uterus) are working fine !

However, the major fear in their minds is that if the doctor cannot find a problem, how will he able to fix it ? Does this mean that I will never get pregnant ?

The truth is that while we are not very good at identifying problems, we are very good at bypassing them !

A better term for unexplained infertility would be undiagnosed infertility - and this says a lot more about the limitations of our diagnostic technology, rather than anything about the patient !

However, when patients are told their diagnosis is "unexplained infertility" they are so hell-bent on finding the explanation ( because how can a doctor provide treatment without first making a diagnosis ?) , that they pressurise doctors into running a further battery of tests. In their mind, unexplained infertility means incompletely evaluated infertility - that the doctor is not been meticulous in completing all the tests . Some doctors are happy to pander the patient's hankering for a diagnostic label ! They start doing all sorts of unnecessary tests ( such as laparoscopy or endometrial biopsy to test for TB). When they finally find a problem ( which is just a matter of time because it is a mathematical certainty that the more the tests you do, one of them will turn out to be abnormal), the doctor then triumphantly proclaims that he has found the elusive diagnosis - which the earlier ( presumably incompetent) doctor had missed because he was not diligent enough.

The danger with this approach is that a lot of these "abnormalities" are just incidental red-herrings, which do not affect the patient's fertility at all. However, now that a problem has been "found", it needs to be treated ! This wastes a lot of time and money while the doctor and patient are barking up the wrong tree. Patients finally end up getting fed up and frustrated - and then refuse to explore treatment options such as IVF which would have allowed us to bypass the problem and achieve success in a much more timely and cost effective fashion !

I just saw an infertile 42 year old woman who said - Doctor, my husband has a low sperm count. Can you please prescribe some medicines so we can improve it and have a baby. "

It always amazes me that even in this day and age so many infertile couples do so little to try to make sense of their treatment options.

Many find it very hard to decipher the medical terms their doctor uses. They do all the tests the doctor asks for - and are often completely lost when he then explains to them what the next action steps are.

Unfortunately, many doctors also "complexify" matters rather than simplifying them. They take a perverse pride in doing so, because it allows them to position themselves as experts in a difficult subject which the poor patient will never be able to understand !

I think they just make matters unnecessarily complex. Infertility is quite a simple topic, when broken down into its component parts.

Basically, you need just 4 things to make a baby - eggs; sperm; uterus and tubes.

If you are not getting pregnant, you need to identify what the bottlenecks are; and prioritise these, so you can focus on the important ones !

Thus, for this 42 year old woman, even if her husband has a low sperm count, her major problem is her advanced age, which is going to impede her ovarian reserve. Even if her husband had a normal sperm count, she would still need IVF, because time is now at a premium for her !

Using this simplified approach, we can quickly get to the heart of the problem - and then identify a solution which allows us to tackle the problem efficiently ! Every problem has a solution - and the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby . The quality of a doctor’s answers depend upon the quality of the patient’s questions - and if patients learn to ask the right questions , their chances of getting the right treatment will improve dramatically !

I got an email from a patient whose fallopian tubes were blocked at the fimbrial end. I explained to her that her best option would be IVF.

She was very concerned about how expensive IVF was; and wanted to explore alternative options. She sent me a link to this website - Blocked Fallopian Tube Kit (USA & Canada)
http://biotanicalhealth.com/products/blocked-fallopian-tube-kit-usa-canada and asked me my opinion as to whether this would be useful.

Visiting this site made my blood boil - and also taught me a lot about how people will prey on an infertile patient's desperation and ignorance and take them for a ride. It's also a great example of clever marketing ! The manufacturer has cleverly packaged a few herbs, tampons, books and DVDs ( costing about US $ 50) - and is selling them as a Kit ( for over US $ 500 ) to help women with blocked tubes get pregnant ! It's a great selling job because the site has testimonials and long-winded explanations as to why this kit works ( all of which are just hot air ) If this actually worked, I'd be happy to close my IVF clinic and send all my patients to this person ! The reality is that this is all marketing hype, which is being used to exploit infertile couples.

The only way couples can protect themselves from such quacks is by arming themselves with Information Therapy !

We treat patients from all over the world and many of them want to do a phone consultation with me before coming to our clinic for an IVF treatment.

I can understand why they want to do so - after all, going half way across the world to get treated by a doctor you've never seen or met is a major leap of faith - and talking to the doctor can help to reduce some of this anxiety !

While it's true that the human touch is very important in providing good medical care, the truth is that it's not humanly possible for me to do so. This is true for many reasons.

For one, because of time zone differences, it's quite difficult to find a time slot which suits both the patient and me. We often end up playing phone tag - causing even more frustration ! Also, phone connections in certain countries ( such as Africa) are not of good quality, so that it's hard to hear each other. Also, sometimes patients forget some of their questions ( not all of them are well organised enough to prepare a list of their questions) , which means they often need to call twice or thrice ! Also, sometimes they do not understand what I am saying , because I may use a medical term they are not familiar with and it can be hard to explain everything in detail on a phone call . Another problem is that the husband calls me ; and after I finish answering his queries , his wife calls in another 5 minutes for additional clarifications, because he could not explain to her what I told him ! And when I am busy seeing patients in the clinic , it's hard for me to spend time on the phone . This means that my phone conversations are often short , which gives patients the wrong idea that I am curt or rude !

However, my major argument against a phone consultation is that it is not a very efficient means of communication ! There is no documentation , and too much scope for confusion and errors. This is why I prefer email, where everything is written down. I can answer as many questions as the patient has - and the patient can share this information with friends or family members who are doctors or nurses , to make sure I am providing sensible advise. They can also cc their spouse, to make sure everyone is on the same page. Because we can store and refer later on to this email conversation trail, there is no scope for ambiguity; and no confusion about medications or their dosages .

It's also much easier for me to answer more complex questions in case more clarity is needed, because the patient can ask for more details in his reply, in case he does not understand something I have said. Moreover, the advise I can provide by email is far more sophisticated and reliable as compared to a phone call, because I can think carefully before sending the email ! Email also allows the patient to send me all their medical records, so I have all the medical details I need to provide intelligent answers , customised to the patient's medical history !

A major benefit with email is that I can provide links to the relevant pages on our website, so they can get even more detailed information about their specific problem. While some patients email is much more impersonal than a phone call, I believe email is much more efficient, when used intelligently !

This is why I request patients who want to talk to me to send me their medical details by filling in the free second opinion form instead, so I can guide them properly. Some get upset with me because I refuse to talk to them on the phone - while others understand that I am doing so in

One of the major reasons patients do not want to do IVF is their fear of injections. They know that during IVF they need to take injections for many days - and many patients are understandably reluctant to take these shots because they have been told that these injections are painful !

While it's no fun to take injections , the good news is that the injections used for IVF treatment are not painful !

Lupron and Anatgon ( which are used for downregulation) and given subcutaneously, just like a diabetic takes insulin injections. these are easy to self-administer and are not painful.

The injections which are used for superovulation ( the urinary gonadotropins such as Menogon) used to be given intramuscularly. IM injections are more painful than subcutaneous injections, because a larger volume needs to be deposited in the muscle; and because the muscles have more nerve endings than the subcutaneous fat. However, these are water soluble , and the pain is usually easy to handle. Using simple tricks ( such as ice-cubes to numb the area; or EMLA patches ) can help in managing the pain.

The good news is that the newer injections used for superovulation - the recombinant gonadotropins such as Follistim and Gonal-F; as well as the highly purified urinary gonadotropins
can also be given subcutaneously. These are not painful at all ( but are more expensive than the IM shots).

So why do IVF patients have the notion that the injections used for IVF are painful ? The painful injections are the oily progesterone injections which used to be given deep intramuscularly for luteal phase support after the embryo transfer. These are the shots from hell which patients never forget - and which leave a major scar - both in the mind and in the butt. In fact, it's these injections which often put patients off IVF treatment for ever !

The good news is that we do not use these at all - and many IVF clinics have stopped using them altogether ! Instead of giving the progesterone intramuscularly, we give it vaginally, in the form of a suppository. While this is messier, it's completely pain -free - and our patients are much happier !