Dr. Aniruddha Malpani

Spanish Doctor
Image by :: Wendy :: via Flickr

Dr. Aniruddha Malpani is one of the best Infertility Specialists in India. He completed his MBBS from Seth GS Medical College, Bombay, in 1982. He took his DGO and MD degrees from Bombay University. He passed his D.N.B. appearing for the National Board of Examinations. Dr. Malpani has been the recipient of a glittering array of prizes, awards and scholarships through his academic years.

Currently, he and his wife Dr. Anjali Malpani, both infertility specialists, are in private practice.

Dr. Aniruddha and Dr. Anjali Malpani have started India’s first Sperm Bank in Bombay, for therapeutic insemination by using donor cryopreserved sperm The Bank has a full-fledged infertility unit, which provides comprehensive services, including IVFGIFT and micromanipulation. The doctors have achieved the first pregnancy in India using the sophisticated technique of PGD (preimplantation genetic diagnosis), which allows a screening of embryos for genetic abnormalities. They have also started India’s first support group for infertile couples, a registered charitable trust, called Infertility Friends.

Dr. Malpani believes in empowering the public with health awareness, as a means of promoting its health, and helping itself prevent and treat ailments in partnership with doctors. He has founded the Health Education Library for People, India’s first Consumer Health Education Resource Centre with reading, browsing and other library facilities. It has a collection of books, magazines, journals, CD ROMs, and videotapes covering all aspects of health explained in terms, which the lay person can understand.

Dr. Aniruddha has, with Dr. Anjali Malpani, authored two books: Getting Pregnant – a Guide for the Infertile Couple, and Best Medical Care A Guide for the Intelligent Patient. He has published articles in several national and international journals. Memberships: He is a member of the European Society for Human Reproduction and Embryology, Brussels, Belgium.

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Dr Malpani – Why do I have to wait 2 weeks to do a pregnancy test

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.

Dr Malpani – Testing for pregnancy after an embryo transfer in an IVF cycle

While all IVF patients understand with their heads that not every IVF cycle results in success, in their heart of hearts, every patient expects to get pregnant every time they do IVF ! This is why the 2ww after the embryo transfer can be so nerve-wracking ! Am I pregnant or not ? Have the embryos implanted or not ? The suspense during the 2ww can be even worse than the pain of the IVF injections !

Most patients would love to have a test which will allow them to find out if they are pregnant immediately after the embryo transfer ! Have the embryos stuck or not ? Why can’t we do a pregnancy test and find out right now ? Even if I am not pregnant, at least it’s better to know than to be unsure.

To understand why patients ( and their doctors ) still have to suffer through a 2 week wait to find out the outcome of an IVF cycle, let’s look at the biological basis of pregnancy tests and how they work.

A pregnancy test measures the amount of beta hCG ( human chorionic gonadotropin) that is in your body. HCG is a hormone which is produced by the trophectoderm cells of the embryo. It is produced in detectable quantities only after the embryo implants. Since implantation occurs 3 – 8 days after the embryo transfer ( depending upon whether you have had a Day 3 transfer or a blastocyst transfer), this means that the HCG produced by your embryo will be first detectable in your bloodstream only after this time.

As your pregnancy progresses, the amount of hCG in your system will increase. At 10 days past ovulation ( DPO) , for example, the average woman has an hCG measurement of around 25 mIU. This amount doubles to 50 mIU at 12 days past ovulation, and then doubles again to 100 mIU at around two weeks past ovulation. Every woman’s body is different, and there’s a lot of variation in HCG levels from woman to woman !

Home pregnancy tests measure the level of HCG in urine. Different pregnancy tests have different levels of sensitivity which means if you use a home pregnancy test that is sensitive to 100 mIU, it will not tell you that you are pregnant if your level of hCG is only 75 mIU. These tests cannot measure a level lower than 25, so they do not become accurate until a few days after embryo implantation. A negative result before then is meaningless, since there would not be a high enough level of HCG to detect even if you were pregnant. If your test is negative, you should retest after 2 days. This is why taking a pregnancy test too early can lead to inaccurate results. I know it’s hard to wait those extra days and you may want to try much earlier. It’s fine to do this, but please don’t assume that a negative results means that you are not pregnant.
This is also why blood tests for HCG are much better than urine tests. Not only are they more reliable, accurate and sensitive, they also give the doctor a number which he can measure and monitor.

If blood tests are so sensitive, then why not do a blood test for HCG 1 week after the embryo transfer ? Unfortunately, doing a blood test for HCG so soon does not make any sense. This is because there will still be some HCG in your body as a result of the HCG trigger shot ( Choragon or Ovidrel) which the doctor gave you to trigger off ovulation 36 hours prior to egg collection. If you test too early, the test will always be positive, as this HCG will show up in the test and give rise to false hopes ! This is why the doctor needs to repeat the blood test for HCG after 48-72 hours. In a healthy pregnancy, the HCG levels will continue to rise. If they do not do so, this means this is not a viable pregnancy.

Finally, remember that you should do the test even if you bleed. Bleeding can sometimes occur during pregnancy as well – and just because you have had bleeding or spotting does not mean you are not pregnant !

Dr Malpani – What are my chances of getting pregnant with IVF

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 !

Dr Malpani – Top 10 myths about infertility

Probably one of the most enjoyable books I’ve read on infertility is: A Few Good Eggs: Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan. This guide is actually targeted to infertile women residing in the US, and it is designed in the currently fashionable “chick-lit” style. It’s amusingly put together; and it is certainly a breath of healthy air, if you are the type of individual who discovers a sense of humor can help you deal much better with infertility.

This book is loaded with lots of Top-10 lists, and here is their valuable listing of Top 10 Myths Regarding Infertility:

10 Mis(sed)-Conceptions Regarding Infertility

1. Infertility will not happen to me.
2. I cannot be infertile. I already have got a child!
3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages.
4. I am just too young to possess fertility problems!
5. My physician shared with me that i don’t need to visit any fertility expert unless I have 3 miscarriages.
6. I am fit. I work out on a regular basis. I cannot become infertile.
7. I am certainly not infertile. I am just not having good enough sex.
8. A person can easily wait a long period to have a child.
9. Males cannot be infertile. They produce sperm regularly.
10. Normal is a miracle.

Below are my remarks on this list:

1. Infertility will not happen to me.

This really is wishful thinking. The unfortunate truth is that the inability to conceive is a common problem which affects around one in ten couples. This means your likelihood of being infertile is around 10%. Sadly, there isn’t any trustworthy technique of being able to check your own fertility (short of really conceiving a child!). There isn’t any sign or indication or hint that will tip you off that you may be infertile. That is why numerous couples are “pre-infertile” – they get worried (often unnecessarily) as to whether they might have issues conceiving when they fail to get pregnant the very first month they attempt to have a baby!

2. I cannot be infertile. I have already got a child!

I’m sorry. As economic consultants tend to be so keen on reminding us, previous performance is no guarantee of future results! If you had a child previously, this only denotes that you were fertile that time – this can be no promise that a new problem might not have cropped up in the meanwhile which is causing you to become infertile now! This is known as secondary infertility – and is usually is much more annoying, since it is absolutely unexpected.

3. I can easily conceive, therefore i do not have fertility problems. I basically have miscarriages

An extended meaning of infertility includes woman who have repetitive pregnancy failures (miscarriages) – ladies who can’t carry the pregnancy to term. This is because the outcome in both the cases is the same – not being able to have a child to adore and to hold.

4. I am just too young to possess fertility problems!

Regrettably, infertility doesn’t care how old you are! While it’s true that older females possess a significantly higher possibility of being infertile, as they have “older” eggs, young females may also be infertile for a lot of reasons – for example damaged tubes.

5. My gynec told me that I don’t need to visit any fertility expert unless I have 3 miscarriages.

A miscarriage takes place in around 10 percent of all pregnancies. Since this is this kind of a common event, and frequently takes place for random genetic causes which usually do not recur, many doctors will not evaluate women who have experienced only 1 miscarriage. Not just is the assessment a waste of time and funds, it offers very little helpful information. This is the reason why the majority of physicians perform testing only when you have had at least two miscarriages. However, if you require further reassurance after experiencing a miscarriage, please ask your physician as to exactly what he or she can do in order to guide you.

6. I am fit. I work out on a regular basis. I cannot become infertile.

There is simply no connection in between your general wellness and your fertility. For instance, your fallopian tubes may be blocked without creating any kind of symptoms or indications. You have no method of knowing this, until you get them examined.

7. I am certainly not infertile. I am just not having enough sex.

This is a chance only when your lovemaking consistency is less than once a week. If it is much more compared to this, the probabilities of your having sex during your “fertile period” are usually quite high – you most likely will “hit the jackpot” at some period over the course of a year. Nevertheless, improving your love-making frequency is actually a simple (and enjoyable!) approach of enhancing your fertility. However, several women delude themselves and believe infrequent sex is the reason they are not having a baby, because they would rather deny the possibility of their having a medical problem for which they may need medical intervention.

8. Its fine to wait to have a child.

This is actually not a very good idea, for 2 reasons. First of all, if you have not conceived on your own in 1 year, the likelihood of your doing so on your own falls substantially. Secondly, fertility declines as an individual get older, and there is absolutely no point in losing time and decreasing your probabilities of success. Everything in life comes back again, except for time. It is a valuable, non-renewable resource – use it smartly!

9. Males cannot be infertile. They produce sperm regularly.

It is correct that males produce sperm all the time. However, around 10% of males tend to be infertile, simply because they generate poor quality sperm. Some possess no sperm in their semen at all – and there is no method of examining this without performing a semen analysis in the pathology laboratory.

10. Normal is a miracle.

Actually, this is true (just slipped it in to make sure you were paying attention!). When you think about how much precise synchronisation needs to be achieved for a good embryo to implant in the uterus to grow to be a baby, every birth is genuinely a remarkable feat – it’s remarkable how the individual body achieves this with such ease for so many couples!

Dr Malpani – Patients with poor ovarian reserve – flogging a dead horse ?

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.

Dr Malpani – Chocolate cysts – how we manage them at Malpani Infertility Clinic

A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images – we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I’ll be happy to help !