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When doctors are stumped with a difficult patient, they will often refer the patient to a specialist, in order to help them with the diagnosis and management.

However, while specialists can be very skilled at making the right diagnosis, they are often not very interested in helping the patient to learn to live with his disease. This is not an area which is of much interest to them, and not their core competence either.

However, after the diagnosis has been made, the patient's life still carries on - and he is often unsure where to turn for help.

For example, let's look at a young woman who goes to her family physician with the problem of blurring of vision. The physician dutifully refers her to an ophthalmologist, who then sends her on to a neurologist, who makes the diagnosis of multiple sclerosis. The doctors pat themselves on their backs, for having come to the right diagnosis so efficiently - and the patient is grateful that at least now she knows what her medical problem is. However, she still has to learn how to live with MS, and learning how to cope with a chronic illness is often the hardest part of having MS.

Unfortunately, this is something about which none of her doctors is well-informed ! The neurologist knows a lot about demyelination and how this affects nerve function - but he cannot teach her much about how to come to terms with her illness ; and how to manage her activities of daily living. How does she deal with her fatigue ? with a cranky child ? arm weakness ? her fears that she may become wheel chair bound ?

The best source of this expertise is not going to be a doctor - it's going to be an expert patient - someone who has lived with MS for many years, and is willing to share their heard-earned wisdom and experience.

Good doctors have always done this informally for many years - and it's been proven that support groups are a great way of helping patients to cope with their illness. It's now also possible to have online support groups, where patients can reach out and connect with each other.

Doctors can also learn a lot from expert patients. Thus, while a diabetic specialist knows a lot about the metabolism of insulin and how to program an insulin pump, he may not know much about what you need to do about your diet and activity in real life ( for example, when you have to attend a marriage or go out for a holiday). You may think these are "silly questions" and may not want to bother your doctor with these trifles - but the fact still remains that you need reliable answers !

It's best to learn these pearls of wisdom from other patients. They will be much more
empathetic - and their advise is likely to be much more practical, as it is based on their real-life experience - not on what a text book says ! Also, while it may not always be reliable ( because patients can be poorly informed sometimes), at least you know it will be provided with no vested interest !

As i have written earlier, the primary job of a doctor it to teach patients. After all, medical care does not just consist of making a diagnosis or prescribing a medicine. Teaching patients about their illness; what they can do to manage it; and what they can do to remain healthy is an integral part of a doctor's job.

However, as important as teaching is learning. Doctors need to learn all the time. Medical science makes dramatic advances all the time, and doctors have to invest time, money and energy in ensuring they knowledge base is updated and current . This is why doctors read medical journals and medical conferences !

However, a very important teaching tool ( which many doctors sometimes overlook) are patients. Patients can be your best teachers - if you give them an opportunity to teach you ! Patients will not teach you just about the medical details of the disease ( though reading medicine about patients you have actually seen is the best way of making sure that the knowledge "sticks" !) .

Patients can teach doctors how to live; and how to cope with adversity ! Expert patients know a lot about their disease, and can teach a doctor a lot about how his patients can learn to live with their disease.

( And if you are lucky, and your patient is an investment consultant, he can also teach you how to invest in shares and stocks ! )

Happy patients are happy with their doctors - while unhappy ones are happy to blame and criticise their doctor. Doctors seem to have become everyone's favourite whipping boys - they are greedy and just want to make lots of money; they do not have time for their patients ; and cannot communicate well.

It's very easy to blame the doctor, but this is hardly helpful ! Patients need to understand that getting good medical care requires they they establish a healthy doctor-patient partnership - and in order to do this, they need to become expert patients !

This has become surprisingly easy to do, thanks to the net. All you need to do is invest some time and energy - and if you do get lost, there are lots of people who can help, including online bulleing boards and forums; and librarians.

The rewards are well worth it - after all, if you are not part of the solution, you are part of the problem ! You cannot change your doctor's behaviour - but you can change yours ! Do not underestimate your intelligence and common sense - you have a lot at stake ! A big plus to doing so is that armed with the information, you'll be able to find a better doctor !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Doctors come in all shapes and sizes . This is just as well, as patients come in different flavours as well, and in the best of all worlds, each patient will find the doctor with whom they can work best with.

This is why doctors prescribe all kinds of therapy - medicines; injections; vaccines; acupuncture; supplements; diets; and surgery. However, there are 3 kinds of therapy which all doctors should prescribe routinely, which they often forget to do !

1. Information Therapy. This should be number one ! The word doctor is derived from the word " docere" - which means to teach. Educating patients is critically important, both for the doctor and the patient, so that they both have realistic expectations of what each expects; and what the likely outcome is going to be. There are many tools available for educating patients - and this can be done online; before , during and after the visit; and by assistants as well.

2. Humour Therapy. Humour is one of the most effective coping mechanisms available and a regular dose can help all of us - patients, as well as doctors ! Good doctors try to make the patient feel comfortable and at ease and humour can be a very useful tool in doing so. It's a good idea to prescribe Laughter Therapy ! For example, I tell all my infertile couples to watch the movie, Maybe Baby. This is not an educational film - it's a romantic comedy about an infertile couple trying to have a baby. It stars Mr Bean - and most patients find watching the movie helps them cope better with their infertility !

3. Biblio Therapy. Many patients - especially those with chronic illnesses - feel cut off and isolated from the rest of the world. It's hard for them to find someone who understands what they are going through - and this adds to their unhappiness and stress. Reading books about other patients who have dealt with a similar problem can be very powerful medicine ! It helps them to realise that others have "been there and done that" - and this can inspire them to fight back !

These are common sense measures, so why does a doctor have to "prescribe " these ? For one, when a doctor advises a patient to do something, he is much more likely to do it. Even more importantly, it helps the patient to realise that the doctor is an empathetic human being, who has his best interests at heart - he's not just a technician. And finally, prescribing these will help the doctor to become a better doctor , as he learns to see things from his patient's point of view - and become a better human being !

At the end of a consultation, I usually ask my patients - So what have you decided ? What would you like to do next ? After all, IVF is an elective treatment; and infertile couples have many choices. These are very personal decisions, which are best made by the couple themselves, rather than the doctor.

Often, many patients will answer - Whatever you say, doctor !

While it may seem very flattering that they are willing to allow me to make the decision for them, this is actually not a good answer , and I am unhappy when I hear this !

I'd much rather have a patient who took the time and trouble to understand their options, so they could make the decision for themselves . The best decision is one you make yourself

I will not let them make the wrong decision - but when there are choices, patients need to use their best judgment and decide for themselves - they cannot leave everything upto God - or upto the doctor !

Many decisions are too important to leave upto anyone else. While a doctor can provide guidance ( for example, about success rates), his opinion should just be one of the variables you consider when making your final decision.

I agree it's much easier to let the doctor decide for you - but this is not in your best interests, or the doctor's ! After all, the outcome of any treatment is always uncertain, and if you do not get pregnant, you may be resentful. Making your own decision gives you peace of mind you did your best ! It also encourages you to seek out information and take a more active role in your treatment - actions which actually improve your chances of getting pregnant !

There is a shortage of doctors. This is true all over the world because of many reasons. Medical training is expensive and arduous, and not many people are capable of surviving the grind. Also, doctor are unevenly distributed, which means that there are too many in large cities, but not enough in the villages. Finally, a lot of the doctor’s time , energy and expertise is wasted in handling problems which do not really need their expert attention. These are problems which can easily be handled by the patient and his family himself.

The standard solution to the chronic shortage of doctors has always been the standard knee-jerk response - train more doctors ! This solution comes in many different flavours - open more colleges; or create a new cadre of barefoot village doctors. However, these are just short-term fixes - and the problem recurs every few years, because doctors create a demand for their own services. This means that churning out more doctors will never help - it will just exacerbate the problem !

The solution is surprisingly simple - empower patients to take better care of their own health !
How can patients figure out when they need to go to the doctor ( and when they can take care of themselves as home ? ) How do they determine which problems they can solve for themselves and which should make them seek medical attention ? Is this headache a migraine ? or a brain tumour ? Is the fever because of a viral URTI ? or is it TB ? How is the poor patient going to figure this out ? Isn’t that what you need a doctor for ?

Right now the standard response for all patient queries is - Ask your doctor ! ( Isn't it ridiculous that most books and websites on fitness and exercise have this disclaimer - Please check with your doctor before starting an exercise program ! ) All we end up doing is making patients more dependent on the doctor and unnecessarily increasing the doctor's workload ! What we need to do is make patients more independent, so they can fend for themselves !

The trick to making patients do all the work is to develop clever tools which will help the patient to make sense of what is happening to them so they can communicate clearly with their doctor. The vast majority of health problems are self-limited and just need reassurance. They can easily be managed by a phone call or an email.

Doctors can learn a lot from retailers. In the past, customers went to the shop and the shopkeeper would have to physically carry the selected objects and then pack them and bill for them. The shopkeeper was the major bottleneck - and had to do all the grunt work. The new supermarkets make the customer do all the work, thus allowing them to service a much larger number of customers - for much less ! It's true that the retailing ecosystem had to change to allow this evolution to occur ( better packaging; better shelf displays; better branding; and more customer education), but this has now become the standard - and the retail industry is doing very well for itself, thank you !

Here's a simple example . A lot of the doctor's time is spent on taking a medical history. Many busy doctors do not have the time to do this themselves, which is why they get an assistant ( who may not be very competent !) to do it for them. We make our patients do this themselves by making them fill a very detailed and complex form ( see a copy at www.drmalpani.com/malpaniform.htm)

This has many advantages. It saves me time. It ensures the history is complete and that I have not overlooked any important information. Even more important, it helps to educate my patients ( because they need to do their homework to be able to fill in the form intelligently !). It also ensures they are better organised, because they need to collate all their medical test results and summarise their history !

Please note that I do not expect patients to make their own diagnosis ! However, patients are the experts on their problem, and helping them to help the doctor will help everyone !

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 !

Patientology is the study of patients - and this is a core skill which all doctors need to learn, even though there is no textbook or syllabus for this !

One way all doctors can become better patientologists is by teaching their patients how to become better patients ! Good patients make for good doctors - and it's possible to provide patients with a toolbox of skills which they can learn to help themselves.

These tools include teaching patients :

how to keep good medical records
how to talk to doctors
how to ask questions
how to do their homework
how to take care of themselves when they are in hospital

Traditionally, medical care was always provided face to face. If you had a medical problem, you went and saw your doctor for a consultation. He would take a history; examine you; and then decide on what treatment you needed.

This was and is still a good model, because it allows doctors to provide the "human touch" , which is often a key ingredient in providing good medical care. However, as time evolved, doctors realised that not all their patients needed to come and see them for each and every problem.

Many problems are self-limited and resolve on their own, so that they can be effectively managed by reassuring the patient; while others simply need a renewal of a prescription ( for example, for managing a stable patient with a chronic illness). This is why "telephone medicine" is an integral part of medical care today.

As technology has evolved, the internet provides a more efficient way of communicating with a doctor than the telephone, so that online consultations are now standard in many fields.

While there is no doubt that seeing a doctor is very important in a medical emergency; or when the diagnosis is unclear, it's also true that not all medical problems require you to visit your doctor.

There are many downsides to a doctor visit. Doctors are busy - and it can take 2-6 weeks to get an appointment to see a leading physician. Also, a visit to the clinic can be quite disruptive , and may need you take a day off because travelling to the clinic can be quite a time consuming chore. A doctor's clinic can be quite chaotic - and long wait times ( surrounded by sick patients) is hardly conducive to healing.

Also, many times patients know what their diagnosis is. They just need a second opinion; or need to find out the cost of a particular treatment option - information which they should be able to get without having to go through the inconvenience and expense of actually going to the doctor.

Online consultations offer a lot of benefits - and in fact, the quality of care can actually be better in some cases ! An online consultation allows you to get an opinion from a world-renowned expert, without having to travel half way across the world to meet him ! Because the doctor's opinion is based on a review of your medical records, you have to make sure all your tests and treatments are well documented - helping you to become better organised, and thus become a better-informed patient. Also, you do not need to waste time waiting for an open consultation slot , because the doctor's clinic timings are no longer a bottleneck, as a result of which the turnaround time can be much quicker.

When you email your questions, do not need to worry about the fact that the doctor is in a hurry and another 20 restive patients waiting in line to see him. It's possible to ask well-crafted questions to clarify your doubts , so that you have a clearer picture of your options. Often email consultations are more productive because you are not stressed out . When sitting in front of the doctor, many patients forget half their questions - and after the visit, many cannot remember half of what the doctor told them. This can cause of a lot of unhappiness for both doctors and patients. An emailed opinion is in black and while - and you can verify this advise with other specialists and your family doctor ; and also share it with your loved ones, to confirm that you are on the right track ! Finally, an online consultation can ensure you get a more objective honest opinion ! Since the doctor does not know you, he has no hidden agenda, and will not want to push you into doing surgery, for example !

Can online consultations have a downside ? Yes, of course ! There is no personal rapport; and the online " expert " may not be trustworthy or reliable. This is why you need to use this option intelligently ! Also, doctors may not be willing to offer this option, because they are not sure how to bill for their time ( though I am sure this will change, as patients are quite willing to pay for phone consultations and online consultations as well !)

In my opinion, it's very good for both doctors and patients that additional options are now available, thanks to the internet . This option is especially useful for getting a second opinion and we do this routinely at www.drmalpani.com !

It saves me a lot of time and energy; and keeps my patients happy, because they can tap into my expert knowledgebase, without having to come and see me !

In normal healthy fertile females, ovulation with rupture of the mature ovarian follicle and release of the eggs occurs within 38 hours of the surge in luteinizing hormone (LH). However, in a small percentage of women, the dominant follicle will undergo the luteinization process but will not rupture following the midcycle LH surge. This is called LUF (luteinized unruptured follicle syndrome). As a result of the increased progesterone secretion, the endometrium undergoes the secretory changes, but, obviously, without the release of the oocyte , pregnancy cannot occur. This means that the cycles are regular; and hormonal studies ( Day 21 progesterone level) , the basal body temperature curve, and the findings in an endometrial biopsy will all be consistent with ovulation.

This is obviously a difficult diagnosis to make; and can only be made by serial vaginal ultrasound scans to track ovulation. These scans show that the follicle matures; but the dominant follicle fails to rupture. The lack of follicle rupture and the lack of free peritoneal fluid around the time of ovulation are used to establish the diagnosis of LUF. This condition is also called “trapped egg syndrome”.

LUF is more commonly seen in women with endometriosis; and PCOD. Often the diagnosis is made only when patients are being monitored for follicle tracking with serial ultrasound scans. LUF is a “silent” problem; and because it does not cause any symptoms or signs, it’s very easy to miss the diagnosis as well ! Since LH is responsible for inducing follicular rupture, LUF can be treated by giving an injection of Human Chorionic Gonadotropin (hCG) in a dose of 10,000 IU intramuscularly, when the lead follicle reaches 18-20 mm in diameter. Ultrasound can be used to document ovulation. It takes about 36 to 40 hours for the oocyte to be released after the injection. Intercourse or insemination should be timed accordingly. If it still does not take place, the dose of the hCG injection can be increased. If ovulation still cannot be achieved even with an increased dose of 20000 IU , then IVF is the best solution.

In our clinic, we really do not bother to make a diagnosis of LUF ! This is because this diagnosis does not really change your treatment options . After all, if you are infertile, this means the eggs and sperm are not meeting. The next step logically is to then do an IUI – and since an HCG injection is routinely given during IUI treatment to induce ovulation, the IUI automatically helps to treat patients who have LUF !

Also known as "Endometriosis of the uterus," adenomyosis ( adeno= glands; myo = muscle) is a benign condition which occurs when the glandular cells of the uterine lining ( the endometrium) penetrate deep into the uterine muscle (myometrium) and invade into it. Adenomyosis used to be called "endometriosis interna," since it can look somewhat like endometriosis under the microscope . However, this occurs within the muscle wall of the uterus, not on pelvic surfaces as does endometriosis.

Most commonly, the disease affects the back wall (posterior side) of the uterus. When this occurs, the uterus is enlarged usually more than twice the normal size and very hard. The disease may be localized with well-defined borders ; or diffuse, meaning it has no limits or borders. When the disease is localized , it is called an adenomyoma. These adenomyomas can be located at different depths of the uterine muscle .

The disease is often under-diagnosed because many doctors do not consider this possibility . Patients who have localized adenomyosis are often misdiagnosed as having fibroids. Others are just labeled as having a “bulky uterus” or DUB ( dysfunctional uterine bleeding). This disease can only be diagnosed with 100% certainty by doing a biopsy of the uterine muscle, a procedure which is done very rarely ! About 10% of women with adenomyosis have also had endometriosis in other sites such as the pelvic wall, ovaries, fallopian tubes etc. The highest incidence is seen in women in their forties, and though this disease may cause infertility, it usually occurs in women who have already had children.

Symptoms

As with Endometriosis, patients with Adenomyosis may not show any symptoms (asymptomatic). However, women most commonly experience excessive, heavy or prolonged menstrual bleeding and painful periods (dysmenorrhea). The amount of bleeding and cramps is usually associated with the degree of disease involvement and depth of penetration into the uterine walls. Extensive involvement of the uterine muscle can also interfere with the normal contractility of the muscle which then leads to excessive bleeding.

Diagnosis

An exact diagnosis is often difficult to establish pre-operatively because abnormal patterns of bleeding (dysfunctional bleeding) and fibroid tumors can result in similar symptom patterns. Sometimes during a D&C procedure to remove intra-uterine polyps or small fibroid tumors, uterine tissue is removed , enabling a pathologist to make the tissue diagnosis. However, this is often an incidental finding. Pelvic exam findings can reveal a slightly enlarged uterus . In some women, the uterus is enlarged (upto twice the normal size) and can also be tender and “boggy”. Vaginal ultrasound shows the uterus is enlarged and bulky, but it's difficult to make an accurate diagnosis of adenomyosis with ultrasound, since the density of the invading endometrial tissue may not differ sufficiently from the surrounding uterine muscle wall. Occasionally the uterus may be described as slightly enlarged in a symmetrical fashion, with a fuzzy shadowy pattern seen in the muscle wall. MRI can also be used to distinguish adenomyomas from fibroid tumors.
Since no medicine eradicates adenomyosis, medical treatments are frustrating for patients as well as physicians . Since the uterus is a hormonally responsive organ, hormones are the mainstay of medical treatment of symptoms. Your doctor may prescribe birth control pills or progesterone pills or shots. Although gonadotropin-releasing hormone agonists such as Lupron have been found to reduce uterine symptoms of adenomyosis during treatment, the symptoms return quickly after the medicine wears off. Pain pills, whether over the counter or prescription, can be used to tide the patient over rough spots.

Adenomyosis and infertility

The relationship between adenomyosis and infertility is still very controversial . Many doctors believe that adenomyosis does not reduce fertility, since it affects only the muscle wall of the uterus. This means that the uterine cavity and the uterine lining in these patients are normal, which means their fertility should be normal as well. However, real effect on fertility is virtually impossible to know since it is so difficult to diagnose the disease in women who have an uterus.
If an infertile woman is found to have adenomyosis, we usually do not offer any specific treatment for this diagnosis , as this diagnosis does not affect your treatment options !

The feeling of helplessness is never stronger than when you’re ill or incapacitated by disease –you are physically challenged and short of energy, not to mention the fact that you’re unable to go about your daily routine as usual. You depend on your doctor or healthcare practitioner to provide a solution, both temporary (to eliminate the symptoms) and permanent (to get you back to normal). However, if you feel your doctor is incompetent and less than efficient, the feeling of inadequacy is compounded a hundred times or more.

Some doctors are incompetent because they may be under the influence of drugs or alcohol; others may just be preoccupied with their own problems instead of paying attention to you and your illness; and yet others are just not capable enough. If you feel your doctor is inebriated or using drugs, follow the proper procedure and report him or her for incompetency. This way, you save other patients from becoming a victim of misdiagnosis and other medical errors. If they don’t seem to be giving you enough attention, ask politely that they pay heed to your issue; and if you still feel neglected, it’s time to change doctors.

Faulty diagnoses and repeated treatments could get you feeling that your doctor is not doing the right thing and that he or she is incompetent when it comes to doing their job well. It’s always best to find a different doctor, someone who comes highly recommended by your friends or family members or others close to you, when you’re not happy with your initial diagnosis or method of treatment. When you choose someone that you can trust, it’s easy to believe in their competence and capability.
Remember, your doctor may not really be incompetent; he or she may appear that way to you because you’re not satisfied with their approach to treating you or because you may be prejudiced towards them for some other reason. However, if you sense incompetence, the best thing to do is change your medical practitioner and get another diagnosis from someone else you trust.

A recent study conducted at the Mongan Institute for Health Policy at the Massachusetts General Hospital and Harvard Medical School, Boston, has found that one-third of doctors surveyed did not report colleagues who they knew were incompetent or impaired because of alcohol, drugs or other problems. This is a frightening scenario in deed – if you were to be treated by someone who cannot be trusted by their peers, how good is your chance of recovery?

So if your instincts tell you not to trust your doctor, go with them because it’s your life and health at stake, and find someone else who you believe will be good for you and your family.


This guest post is contributed by Maryanne Osberg, who writes on the topic of RN to MSN Online. She can be reached at mary.anne579@(AT)gmail(DOT)com.

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.

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Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, 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 !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !

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Many infertile women have irregular cycles and they know that the reason for their infertility is related to their irregular cycles. However, many are quite confused as to the relationship. Some naively believe that if the cycles are regularised, their fertility will also automatically improve ! This is why they waste months taking birth control pills, without trying to address the underlying problem !

Today, we know that the commonest cause for irregular cycle is PCOD - polycystic ovarian disease. Unfortunately, many gynecologists blindly diagnose every patients with irregular cycles as having PCOD , without bothering to rule out other possibilities !

Let's look at some basics.

Women who ovulate regularly get regular periods. The reason a woman's periods are irregular is because she does not ovulate. This is called anovulation. While it is true that the commonest cause of anovulation is PCOD, it's equally true that this is not the only cause. A good doctor will do a careful workup to evaluate ovarian reserve, in order to determine what the reason for the anovulation is.

Thus, in some women the reason for the anovulation is poor ovarian reserve - a condition called the oopause. However, if this is mis-diagnosed as PCOD, precious time is wasted and the patient never gets a chance to get the right treatment !


If you have irregular cycles, please insist that your doctor do the following simple medical 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 your cycle, ( to check the quality of your eggs).

2. A vaginal ultrasound scan on Day 3, which should check for the following.

a. ovarian volume
b. antral follicle count

Patients with PCOD typically have a high LH:FSH ratio; a high AMH level; large ovaries; and increased ovarian stroma with many small antral follicles.

Patients with poor ovarian reserve, on the other hand, have a high FSH:LH ratio; low AMH levels; small ovaries and a reduced antral follicle count.

If you are not sure how to interpret your reports, please send me your medical details by filling in the free second opinion form , and I'll be happy to help !

A new set of interactive guidelines have been created to help clinicians more effectively communicate when they deliver bad news to patients.

COMFORT is an acronym that stands for Communication, Orientation, Mindfulness, Family, Ongoing, Reiterative, and Team.

Communication- Clinicians need to learn to how to use clear and familiar language
when breaking bad news. Patients are people and have the basic right of receiving information in a manner that makes sense to them. Communication between doctors and patients should strive to be person-centered and nonverbally direct.

Orientation- Low health literacy leaves most patients and their families with little choice
about their care. A patient receiving bad news will be overwhelmed, and will often respond to any clinician recommendations, even if they are ineffective. Treatment outcomes should be clearly articulated in language that is appropriate for both the age and education level of the patient.

Mindfulness- Doctors need to learn to treat each patient interaction separately. When
delivering bad news, the patient should be at the center of the doctor’s attention.
Focusing on a patient’s individual experience requires doctors to avoid basic scripts and protocols.

Family- Families should be included in conversations when doctors break bad news
to patients, since families provide support to the patient. Families are also affected by illnesses, and clinicians need to address both the patient and their family.

Ongoing- Clinicians must emphasize that the patient will not be abandoned after a
diagnosis, or while they receive ongoing treatments. By continually communicating with patients, clinicians can provide more clarification about the diagnosis, especially if the recovery will not be quick.

Reiterative- When interacting with a patient, clinicians need to keep the meaning behind
their messages the same, even if the message delivery takes different forms over time. The message must always adapt to fit the needs of the patient.

Team-Patients receive care from a team of medical professionals, including physicians,
nurses, chaplains, psychologists, and social workers. Communicating as a team will help reassure patients and their families that they will be receiving proper care.

This study appears in Volume 59 of Communication Education, a publication of the National Communication Association. For more information about NCA or its journals, please visit www.natcom.org.

I just saw a very distressed young man . He had been married for 3 years, but had still not been able to get his wife pregnant. His wife had got all her tests done, and her gynecologist had confirmed she was fine . She then asked him to get his semen analysis done, and this is where he was stuck . The problem was that while his libido was fine, and he had an active sexual life, he had been unable to get his semen analysis done. Every time he went to the lab for a semen analysis, they told him that they were unable to do it, because there was nothing in the container that they could analyse !

His gynecologist dutifully referred him to a surgeon, who examined him and confirmed he was normal. He asked him to go to another lab for his semen analysis - with exactly the same results !

The doctor told him blankly - If you cannot get your semen analysis done, I cannot help you, sorry ! He then changed another two doctors. One suggested he visit a psychiatrist, to help with his "erectile dysfunction"; while another suggested that they could do a testis biopsy to see if sperm were being produced in his testis or not.

He was completely fed up. " Doctor, I know I do not have impotence or erectile dysfunction ! I get a perfectly adequate erection - it's just that I have not been able to get my semen sample tested so far , because when I get an orgasm, nothing comes out of my penis ! I am not an idiot ! Why don't my doctors believe me ? And why can't they help me ? Am I a freak ? "

The problem is that the eye only sees what the mind knows, and many doctors are not comfortable dealing with the infertile man because they do not have much experience in handling these patients. While they learn now how to manage common problems such as erectile dysfunction or azoospermia ,they are surprisingly clueless when dealing with uncommon problems ! And if the patient does not fit into their pre-existing notion of the correct diagnosis, they are quite happy to adopt Procrustean techniques until the square peg fits into the round hole !

The first thing I did was sit down and take a detailed history, probing systematically into the following steps :

sexual desire;
erection;
ejaculation and
orgasam.

He had no problems with libido; his erection was satisfactory; he got an orgasm; but there was no ejaculation even after he got an orgasm. This meant his problem was orgasmic anejaculation , also known as aspermia.

The commonest reason for this is that the man ejaculates his semen backwards into the urinary bladder. This is called retrograde ejaculation. I told his to get his urine tested after his next orgasm - and just as I suspected, there were lots of sperm in his post-orgasm voided urine sample ! When I showed him these under the microscope and told him we could use these for ICSI , I was gratified to see a big smile on his face. " Thanks so much, doc ! It's such a relief to know I am not a crackpot and am not going crazy. None of the other doctors would believe me !"

He was grateful, not just because I had made the right diagnosis and could offer him an effective solution to his problem, but because I had treated him and his complaint with respect. I had used the oldest therapeutic tool of a healer's armamentarium - a patient hearing !

All I had done was listen to him; and translated his complaint into medical terms, which I could then analyse intelligently. The other doctors had just tried to lump with all the other common problems which they see daily - and when he did not fit, they labelled him a crock !

The truth is that not all patients will have garden variety problems - and the most important tool for solving rare problems is a detailed history ! This is very low-tech and inexpensive, and rarely inspires awe, but is the differentiating factor between a good doctor and a run of the mill physician. An expert doctor knows how to take a history; which questions to ask - and which to probe further !

" Listen to your patients. They will tell you what is wrong with them." This is an aphorism which is often attributed to Dr William Osler. This is as true today as it was centuries ago !