LEARN INSURANCE

I see many patients who have failed IVF cycles in other clinics. In order to improve their chances of success, I ask them basic questions about their earlier cycle: How many follicles did you grow ? How many eggs were retrieved ? What was your embryo quality ? Surprisingly, many are quite clueless , and know very little about the medical details of their treatment cycle, because " my doctor did not tell me anything " ! They are often upset and angry- and resentful that their doctor did not share more information with them.

After realising how much their doctor has kept them in the dark, they conclude that they made a mistake in the doctor they selected. They feel cheated and start believing that they can no longer trust any doctor.

One of the reasons for their bad choice is because they did not do any research or homework before starting their IVF treatment. Many people just go to the nearest IVF clinic - or just blindly follow their family doctor's advise.

This is not a happy situation, and ends up hurting both good doctors and patients. It's especially tragic when IVF patients who have had a bad experience refuse to try another doctor, because they then lose the opportunity to take treatment with a good doctor !

When you make a mistake, you should learn from it; forgive yourself; and move on. I tell all my patients - It's OK to make a mistake once - just make sure you don't make it again !

Try and try till you succeed....i think this mantra holds not only in your professional life but personal too....

After two years of trying for baby and undergoing two laproscopies ,two iuis and one failed ivf we were devastated....we thought we can never have a child of our own....but then by God's grace we came across the web site of Dr Malpani..Oh it was so informative! i posted my history and there came a very positive reply..there was a ray of hope...we made up our minds to give ourselves one more chance so that we don't repent later.

We visited Dr Malpani clinic in May 2009 for the first time and i must say there is something in his clinic..i think its God's blessing to them...the environment is so positive and cordial and Dr Malpani is so very approachable and positive too that we immediately felt we had come in right place and were in right hands.

We underwent two IVF cycles one in July and other one in Oct 09 but unfortunately both resulted in chemical pregnancies....however we were still happy that atleast something was happening..i was getting pregnant which had never happened before! Then our 3rd cycle was a ZIFT in Feb10 which also did not work out....but atleast our embryos were frozen for future. Our 4th cycle was planned in Aug10 ie IVF with frozen embryo transfer.I must say since our embryos were frozen so this cycle was very very less stressful and required just two visits to the clinic!...AND THIS TIME GOD WAS WITH US..

YES i got pregnant in this cycle that too with twins!! Our joys knew no bounds...we were on CLOUD9!! We immediately informed Dr Malpani about it..he was also very happy for us.
Presently i am in 32 weeks of pregnancy and just waiting to hold my babies in my arms and even now Dr Malpani calls up and asks for my well being and answers all our queries inspite of his busy schedule and mad rush in his clinic. This shows his true dedication for his patients.
I WOULD RECOMMEND Dr MALPANI TO EVERYONE TRYING FOR THE BABY.THEY ARE TRUE PROFESSIONALS.

I must also mention about Dr Anjali who has an equal or rather more role to play along with her husband.She is a sweetheart and very professional.She is the one who did all my transfers and finally made me pregnant! Also Dr Sai,the embryologist and all the staff in the clinic are true professionals and do their jobs very well....that's why the success rates are so high. I would like to wish them all the best for future and may they continue to do the noble cause.

neha_sh1980@rediffmail.com

This is one of the commonest questions patients ask me. A good IVF clinic is quite good at making good embryos in the lab. However, once they are transferred into the uterus, then whether they will implant to not is a biological process which is not in anyone's control ! It can be quite scary to think that the fate of your embryos is in your hands - and that if you make a false move, you may lose the embryos !

The actual IVF treatment, leading upto the egg collection is full of action ! You are taking injections every day and the doctor monitors you closely. It's fun watching your follicles grow on the ultrasound screen and actually seeing your embryos can be a very emotional moment in your life ! However, after the embryos are transferred, you are pretty much on your own. You have no idea what's happening to your precious embryos inside your uterus and there's no medical monitoring or contact, so you are pretty much in limbo until the day of the HCG test. Not for nothing do women dread the IVF 2ww !

Your mind plays all kinds of games with you ! Are your breasts feeling fuller than usual ? Was that a uterine cramp ? Does the discharge you are getting mean the embryos are falling out ? Does the backache mean the cycle has failed ? Is the bloating PMS or an early symptom of pregnancy ?

You try to compare notes with other women - but realise that there is so much variability and so many old wive's tales, that it's hard to make sense of anything which is happening to you. Your imagination runs riot - and your husband can be completely unhelpful when he tells you to "stop stressing out" and to "just relax" !

It's difficult to find anyone who can empathise with the suspense and anxiety you find yourself in - and every hour seems to last for one day . You are petrified that a false move will jeopardise your precious embryos ! Is it safe to run to catch the bus ? Is it OK to drive ? Does straining in the bathroom cause the embryos to get dislodged ?

Just what's happening in your uterus ? Are the embryos implanting ? Or dying ?

The truth is that there's very little you - or anyone else - can do to affect the outcome of the cycle after the transfer is over - it's very much a "no-woman's " land ! Because human reproduction is an inefficient process, most embryos do not implant to become babies. This is true in the bedroom as well, but when the embryos do not implant after an IVF cycle , women always blame themselves !

" I killed my embryos ! I let my family down ! I will never give my husband a baby ! I am cursed ! I failed again !" These are familiar refrains you may hear, even though you do your best to remain calm and collected.

What makes a bad situation worse is how clueless your husband can be ! He often does not know what to say - and what he does say, he often does badly. He may say things like - " Don't worry - it's not the end of the world ! " " I am sure it will work the next time !" And you feel like saying - " You are an idiot if you do not realise it is the end of my world ! " " And how do you know it will work the next time ? " The poor guy is just trying to provide moral support, but you may find yourself taking our your anger on him !

And the "well-wishers" who blame the IVF failure on the fact that you did not rest or took too much stress are often the last straw which can break your back !

Please do not beat up on yourself ! While doctors do provide luteal phase support with hormones to try to improve the chances of successful embryo implantation, the truth is that the outcome of every IVF cycle is always unknown. All you can do is to improve your odds by finding a good clinic - the rest is outside your hands !

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.

One of my patients recently asked me - Which protocol is better for IVF - the Letrozole Antagonist Protocol vs the Estrogen Priming Protocol ?

( In passing, I'd like to point out how impressive it is that patients are so well informed about medical minutiae ! Most gynecologists are quite unaware of all these finer details !)

Actually, the principles of any superovulation protocol for IVF are extremely simple. Superovulation forms the heart of modern IVF. We use medications to help you grow more eggs. Every month you start to grow about 30-40 follicles, but in a natural cycle, most of these undergo atresia (die), so that only one matures every month, in the normal course of events. With the help of medications, we are able to rescue follicles which would otherwise have died, so that we can help you to grow many mature eggs in one cycle.

Since follicles grow in response to the hormone FSH ( follicle stimulating hormone), this is the most important medication we use for IVF. This comes in many different forms . The traditional medicine has been urinary gonadotropin ( menotropin or human menopausal gonadotropin). Brand names include Menogon and Repronex ). This has been the work-horse of IVF for many years and is still the most cost effective medication available !

The gonadotropins now come in many new ( and much more expensive !) flavours, including the recombinant ( rec) gonadotropins, which are produced in vitro in a bioreactor. These are the rec-FSH and rec-LH preparations, and brand names include Gonal-F and Follistim. All these are very similar as far as their clinical activity goes , though the recombinant drugs are much more expensive ( and are therefore promoted much more actively, even though they are no better !)

We can also use tablets such as letrozole to help you grow more eggs. These act by boosting the prodction of your own gonadotropins, thus helping you to grow more eggs.These are much gentler and much less expensive , and are very useful for the minimal stimulation IVF programs.

So if all we need to make you produce more eggs is to superovulate you with medications, why is this such a big deal ?

Remember that we also also need to prevent the eggs from bursting on their own. We need to time egg collection in an IVF cycle very precisely. We want to collect mature eggs before the follicles rupture. We cannot afford to go in too early ( or we will get only immature eggs); and neither can we wait too late ( or the follicles will rupture and we will lose the eggs).

Since we know that spontaneous follicular rupture is triggered off by an endogenous LH surge which is initiated by the pituitary gland, the drugs we traditionally use to prevent this spontaneous follicular rupture are the GnRH agonists. Brand names include Lupron and Buserelin ; and these switch off your pituitary gland, preventing it from producing any LH. However, they take a long time to act and need to be given for at least 10 days in order to be effective. These were administered as either a long protocol ( from Day 21 of the earlier cycle; or a short protocol ( starting from Day 1 of the cycle).

The newer generation of drugs which allow us to equally effectively prevent the spontaneous LH surge are GnRH antagonists, such as Ovurelix and Cetrotide. These act much more quickly, which means they can be started from Day 7 onwards, which means you need to take fewer shots ! However, these are much more expensive , as compared to the GnRH agonists, and are no better than them as regards their clinical efficacy.

In reality, pretty much any protocol works well for patients with good ovarian reserve, so there's not much to pick and choose between them, and most clinics get good results with whichever protocol they are comfortable with.

However, some patients can be quite tricky. These include patients with PCOD, who have a high risk of getting OHSS. They need much gentler superovulation, and closer monitoring.

The really difficult patients are the ones with poor ovarian reserve. They have fewer eggs left in their ovaries, which means they respond poorly to the standard superovulation protocols.

It is for these patients that doctors have developed newer protocols, in the hope that we will be able to coax these ovaries to produce more eggs !

A lot of the emphasis is on precycle preparation. The hypothesis is that if we treat patients prior to starting their IVF cycle with estrogens ( the estrogen priming protocol) or androgens ( such as DHEA) , they will produce more eggs because more follicles will be recruited when we start the superovulation . Many doctors will also use supplements like wheatgerm , Vit D3 and CoQ 10; as well as alternative medicine ( yoga and acupuncture) to boost ovarian response.

So much for the basics . However, I find many IVF doctors seem to deliberately complicate matters . They love coining fancy new names for their "new" protocols ( which are actually very similar to each other in reality !)

Why do they do this ? I think there are 2 reasons. If you use long complex technical names, this helps to put patients in their place . If you make it complex, patients don't ask too many questions because they are out of their depth, and they respect you even more because you are the expert who has mastered all these esoteric medical details !

Doctors also have a fascination for anything which is new . Doctors like to innovate - and it's fun to design and do something new !

Finally, it's a clever marketing ploy, because it helps to attract patients who have failed IVF cycles elsewhere. Patients who have failed IVF are desperate to do something different ( and preferably something new !)

Just remember that new is not always better - and please try to understand the principles behind the treatment, so you do not get taken for a ride !

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 !

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 !

While most patients can handle the medical bits and bobs of an IVF treatment cycle quite easily, dealing with the anxiety which an IVF cycle involves can be very challenging.

I just saw a 38 year old patient who had a low AMH level. She had been advised IVF, and wanted a second opinion as to whether this was a good option for her.

Given her advanced age and her low AMH level, I told her that she had reached the oopause. I agreed that she needed IVF, because time was at a premium for her.

When I said this, she because very agitated. I did my best to try to calm her down, but she seemed to get even more anxious.

" What are you worried about ? Pain ? side effects ? the expense ? "

" No, doctor, I am worried that I am now too old. I know that my low AMH level means my eggs are poor quality, and that there is a high chance that the IVF cycle may fail and I may never have a baby !"

The fear of failure is the biggest concern for most patients who are considering doing IVF. However, many manage this anxiety very poorly.

For one, they do not articulate it well, so that it then becomes a diffuse general free-flowing anxiety which starts disrupting their life. Some prefer remaining in a state of denial, because they just cannot screw up their courage to face up to the ugly truth that not all IVF cycles result in a baby. Others prefer keeping a "positive attitude" because they naively believe that if they are optimistic, "all will be well" - and that unnecessarily stressing about the outcome can reduce their chances of success

I feel that patients ( and their doctors) should acknowledge upfront that IVF can be very emotionally stressful and that all patients going through IVF are likely to be anxious. While it's easy to relieve some of the anxiety ( for example, about hormonal side effects and the fear of pain) with information therapy, many of these concerns cannot and should not be pooh-poohed away. It's far better to allow the patient to ventilate and express her fears, so these can be managed properly. Unexpressed anxieties are likely to fester and cause emotional scarring later on.

Is there any quick fix ? Unfortunately, no. Most patients are intelligent enough to know that it's not sensible to worry about something which you cannot do anything about - but while the mind understands this, it's hard to get the heart to agree !

I tell patients that you are paying me , so please let me do the worrying for you! My worries are about medical concerns , which are likely to lead to constructive solutions ( how can I tweak the superovulation to maximise chances of success) - so you can focus on growing lots of eggs !

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.

It breaks my heart when I see how poorly patients are informed about their IVF treatment. It seems to be a conspiracy of silence - and most doctors seem to be extremely stingy about sharing medical details with their patients . I find this very difficult to understand - after all, the patient has a legal right to their medical records.

Many IVF clinics provided printed treatment summaries - which conceal more than they reveal.

I have attached an image of a " treatment summary" of a patient who had IVF done in a leading IVF clinic in Delhi ( name removed to protect the guilty !).

While it seems quite impressive , there is no medical information in it at all ! The doctor does not even specify how many eggs were collected !

There are no details about the embryo quality - or even how many embryos were transferred !

When I see records like this, I wonder what the doctor has to hide - and
why !

Patients get what they deserve - and unless IVF patients start demanding photos of their embryos, I do not think the state of affairs is going to improve !

I will often ask my patients for their inputs during their IVF treatment cycle. I feel patients should be well-informed and I see my role as a technical facilitator . My goal is to empower my patients so that they can make the right decisions for themselves and not have to depend upon me.

When I ask my patients to decide, many of them look at me as as I was crazy. Most Indian patients are used to dealing with doctors who have a much more paternalistic style, and most are used to being told what to do by their doctor.

A common response to my question , What would you like to do ? is - But I am not a doctor ! This has 2 sub-texts - You are the doctor, which means you are the expert, so you should decide. Secondly, because I am not a doctor, I do not understand much about IVF, so do not feel I can make the right decision.

While it's fine to ask your doctor for his opinion, I feel patients underestimate their ability to understand IVF and make the right medical decisions for themselves. IVF is not rocket science - and a good doctor will help you understand what is happening , so you feel more capable of deciding for yourself ! I tell patients that I am the doctor; that the buck stops with me; and that I will not let them make a wrong decision - but that when there are choices ( and there always are choices in elective treatments like IVF), it's best that they decide !

Some patients are happy to be treated as equal partners - while others will find a more authoritarian doctor , so they do not have to do any thinking for themselves !

I know lots of doctors, but most of them are not very good at handling money. The fact that they got into medical college means they are bright and must have been in the top of their class, but most of them have very little business sense. Why is this so ?

Even though every clinic is a small business, most doctors have no exposure or training in business management . While they are very hard working and intelligent, they are often not good at managing other people or building teams.

Sadly, most of them are not willing to learn . One of the occupational hazards of being a doctor is that because they did so well academically, many of them they think they know it all , and cannot be taught anything. How sadly mistaken they are ! If you do not know what you do not know, how will you ever learn new stuff ?

Most doctors do not have role models they can emulate. Doctors are often intensely political and competitive. They are secretive and not willing to share what they have learnt with their colleagues - which means that most doctors have to make their own mistakes in order to get ahead.

Most doctors are in solo practise, which means they are stuck thinking small most of their lives. In their first decade of practise, they are so busy trying to attract patients, they they often lose sight of the big picture. By the time they become more mature, they are already ready to retire !

Sadly, giving cuts has become the norm today and most doctors are so used to taking shortcuts in order to build their practise, that they lose sight of basic customer service principles. This means that rather than spend time and energy keeping their patients happy, they waste a lot of it networking with colleagues who refer patients to them . Because these colleagues think the same way they do, there is very little attention paid to growing the business ethically.

Some senior doctors take a perverse pride in the fact that they are not interested in earning money ! They consider medicine to be a service profession and feel that earning money is below their dignity . They will often look down ( or pretend to do so ) upon doctors who are richer than they are.

Most doctors do not use technology cleverly. While they are often aware of the latest gadget and gizmo in their own specialty, they are often not smart enough to use technology for managing their clinic , growing their practise or marketing themselves.

Many are woefully financially naive. When they first start practise, they are so used to working for free that they do not think about paying themselves at all ! When they start their clinic, they treat the clinic's income as their personal income. However, this is actually the income of their business - they should only be paying themselves a salary as a CEO. The clinic should be profitable enough to pay them a salary and should be able to run without their presence ! Most doctors are so busy working in their practise , that they fail to work on their practise !

Doctors do not learn to leverage their strengths; and because they are so busy competing with each other , they do not learn to cooperate and grow the pie for their profession. They fritter away the goodwill they have earned from their patients on personal gratification. Sadly, the leaders of the profession are intensely political , and because they are so focussed on looking only after their personal selfish interests, they do little for the profession as a whole. By the time they are senior and are capable of looking at the big picture, they are thinking about retiring !

Most doctors are good at what they do, which is taking care of their patients . While this is good for their personal wellbeing, it's not good for the profession, which lacks leaders who can provide wise counsel for their colleagues and peers.

When patients have a medical problem, they come to doctors asking for help . They expect the doctor to provide solutions ; and the traditional model is that the doctor reviews the problems and offers the right treatment. The patient complies with this and gets better, so that everyone is happy.

In real life, things are far more complex.

What happens when the doctor and patient do not see eye to eye ? What if the patient is not happy with the solution which the doctor offers ? Usually, patients are scared of doctors and are reluctant to express their disagreement openly. Most will nod their heads, pretend to agree - and then walk out and find another doctor ( if they can afford to do so) who provides an alternative solution they are happier with. However, this is not a happy solution, either for doctor or for patient !

This is actually even more complex in areas like infertility treatment, which is elective and is done primarily to fulfill a patient's personal wish to complete their family.

So what's my approach when I do not agree with my patient ?

I try to follow a model of non-directive counselling. I believe my role is to help the patient to make a decision which is right her her. I do not walk in my patient's shoes, and cannot possibly know what her pain points are ! Often patients will make decisions I may not agree with personally. Nevertheless, I am happy to support them , because my role is to facilitate them to finding their personal happiness.

However , I am also a professional, and the buck stops with me. I promise my patients that I will not let them make a wrong decision which can harm them.

Let's look a patient I saw recently. This was a 45 year old woman who had reached the oopause. She had a high FSH level ( 15.6 mIU/ml on Day 3) and a low AMH ( 0.2 ng/ml) level. Her chances of conceiving with her own eggs were bleak, and I told her that her best option would be to consider using donor eggs. However, she was strongly against this, and wanted me to do IVF with her own eggs. I did my best to explain to her that the chances of success even with IVF were very poor, but she had already made up her mind.

"Look, doc. I cannot do the IVF in my own bedroom. Will you please do this for me ? I understand my chances are poor, but this is what I want !"

I agreed, and did the IVF for her. Her ovarian response was very poor, as expected, and she only grew one follicle. Doing a single egg IVF is very stressful for us, because the chances of failure are so high. I did my best to advise her to cancel the cycle, but she was adamant. " Doctor, one egg is better than zero. Please go ahead and do your best - and we'll leave the rest upto God !"

How could I refuse ? She was a very well-informed successful banker, and knew her own mind. We went ahead; got a mature egg. This fertilised and formed a beautiful 4-cell embryo which we transferred on Day 2. I was pleasantly surprised, but told her not to expect too much, because the chances of success were still very poor. 14 days later, she called up, saying - " Doctor, my beta HCG is 200 - I am pregnant !" She now has a gorgeous 1 year-old daughter, who is the apple of her eye. Whenever she comes and meets me, she always teases me, saying - "Aren't you glad I did not listen to you doctor ?"

This patient taught me to change my approach and I no longer tell patients what to
do . I help them to make a list of all their options, so they can choose what is right for them. I tell them to understand the limits of medical technology and encourage them to be well-informed and to do their homework. I suggest a 3-step approach - Use your brains, so you can make a list of all possible options; then listen to your heart, so you can select the one which seems right for you; and then work out the logistics, keeping a Plan B ready !

I no longer get upset when the patient does not agree with my viewpoint after listening to what I have to say. I try to treat her as an intelligent adult, who is capable of making her own decisions. Patients come to me carrying considerable emotional baggage; and many have a worldview which is very different from mine. I am willing to accept these differences, and we respectfully agree to disagree.

If the chances are very poor, and yet the patient insists that I treat her, am I being unethical by pandering to her desires ? Am I encouraging her to waste money by undertaking futile treatment ?

Who is to judge whether or not the treatment is futile ? Even if it does not result in a baby, but gives her emotional closure and peace of mind , should it not be considered to be a success by her personal yardstick ? She is spending her own money - and by acceding to her request, I am being ethical, because I am respecting her autonomy.

I try to act as a sounding board - and sometimes deliberately play devil's advocate, so patients have a better idea of the pros and cons involved in their decision. If they then decide to go ahead, I do my best to maximise their chances of success.

As a result of this approach, I find we have happy patients, who have peace of mind they did their best. This approach also makes for a happy doctor , because I learn a lot from such patients !

These patients are typically very well-informed and well organised. They are making unconventional decisions, which means they are capable of thinking "out-of-the-box".
They have done their homework, and know their own mind. They are not asking me for help with making a decision - they are just asking me for technical assistance, so I can carry out their desires.

I realise I am not God - and neither am I a fortune-teller. I have seen many patients who have got pregnant against all odds, so I am quite contented when they disagree with me. I understand patients need to make up their own mind, so they can move on with their lives.

This approach well with mature patients who understand what I am doing and want to be treated as adults. It's not for everyone - especially those patients who expect their doctor to passively fall in line with their commands; or those who are incapable to making their own decisions, and expect the doctor to do everything for them

These patients are what I call the Expert Patient - and I learn a lot from them daily !

Most patients will vouch for the fact that the care provided in many IVF clinics leaves a lot to be desired. The clinic does not seem to have a treatment plan or protocol - and even if it does, this is not shared with the patient, who is often clueless about what is going to happen next ! There is very little communication amongst the staff, and often it seems that the right hand does not know what the left hand is doing. It seems that all the treatment is done on a daily, ad-hoc basis, and this lack of transparency create a lot of unease and distress. Also, because the senior" doctor is never available , it seems that all the decisions are made by assistants or nurses !

There is often poor communication between the clinic's staff members , who may end up providing contradictory information. The patient's expertise and intelligence is never respected; and most patients end up feeling patronised.

This seems to be true in very large clinics - and in small ones as well.

Thus, in some places, the gynecologist ( who is not an infertilty specialist) will do the superovulation and ultrasound scan monitoring; and then refer the patient to an IVF specialist for the egg collection. While satellite IVF clinics do work well , this is true only when they are tightly controlled and have strict protocols which are closely followed. Unfortunately, when gynecologists do an "occasional" IVF treatment every week or so, they often end up doing a major disservice to their patients , because they do not have the skill or expertise to treat them properly !

This is also true for centers which depend upon a "travelling embryologist" to do the ICSI treatment procedures. While these embryologists are very skilled and in great demand , it's hard for them to be in two places at one time. This means that they are often travelling from center to center, all across the country, and can only be in one center for about 48 hours. This means that the egg collections have to be done in this 48 hour window - and while about 80% of patients will grow eggs at the expected rate, this is not a good idea for older women or women who are poor ovarian responders, who need much more individualised treatment protocols , tailored to their body's needs.

The same criticism is true for the clinics which are run by "big-name" IVF specialists, who fly down from out of town to do the egg collections or embryo transfers once every month. The treatment protocols are monitored by remote control - but as any honest IVF specialist will tell you, this is suboptimal, and not in the patient's best interests !

Similarly, even in some very large IVF centers, the andrologist is available only once a week . This means all the TESE and PESA procedures have to be done on this one day - and the sperm are then frozen and used later for the ICSI procedure . This is not something which is in the patient's best interests, because the survival after freezing testicular sperm in men with partial testicular failure can be very poor !

The truth is that many IVF clinics today are run as commercial enterprises, to maximise profitability, rather to to maximise success rates. Ideally, you should look for an established clinic, which provides comprehensive care facilities under one roof, 24/7 !

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

Malpani Infertility Clinic, in partnership with MyToday, is pleased to announce that we have now started publishing the world's first patient education channels on IVF and infertility.

The mobile is a great tool for educating patients - and using SMS we hope to be able to remove a lot of the myths and misconceptions which surround this emotionally sensitive topic !

You can see all our SMS Infertility Channels here.

You can also subscribe free to our IVF channel here !

At present, this service is available in India only.

The fear of failure is perhaps the commonest reason why most women do not have the courage to try a second IVF treatment cycle when the first one fails.

But playing it safe has risk as well. If you never dare to fail , you will never succeed !

Here's a great post on how to overcome the fear of failure !

IVF can be a complex process and selecting a doctor can be quite a challenge ! Infertile couples are often frustrated and depressed and most will choose an IVF clinic based on a recommendation by a friend or a referral by a doctor. This is not always the best method and you can end up getting stuck in a poor quality clinic, thus reducing your chances of success. Even worse, many clinics do precious little do educate or inform their patients and patients don't know what questions to ask their doctor.

Also, IVF cycles can fail for many reasons. Sometimes the problem is poor quality eggs - but often it is a poor quality clinic !

Here's the single most important thing you should check, to be sure you are getting good quality treatment.

Insist that your clinic provide you with photos of your embryos ! A good clinic will provide this routinely. This is tangible evidence that they have delivered you with a high quality service - after all, the key output of an IVF clinic is the embryos they produce.

What do bad clinics do ?
- They do not provide photos of your embryos
- They fob you off with specious excuses ( our camera is not working is very popular)
- They just just tell you verbally that the embryos are Grade A
- They "show" you the embryos under the microscope. Unfortunately, for most patients, these just look like blobs - and patients are not sophisticated enough to differentiate between good embryos and bad embryos

Whenever a patient comes to me for a second opinion after a failed IVF cycle , I ask them just one question - show me the photos of your embryos. This allows me to judge objectively how good or bad the IVF lab is - and bad IVF clinics have bad IVF labs !

If you are not sure what good embryos look like, please look at this Visual Atlas of Embryos.


And you can always ask me for a Free Second Opinion !