Posts Tagged ‘dr anirudha malpani’

Dr.Malpani- Why does the infertile man get such poor quality treatment ?

As an IVF specialist , I have noticed that infertile men often get very poor quality treatment. There are many of reasons for this.

The first is the infertile couple themselves. Having a baby is usually considered to be the woman’s problem , and she is the one who seeks medical attention which means she usually goes to her gynecologist. Many men have a fragile ego, and while some refuse to go for sperm testing , others postpone this, because they are worried they will find that they have a problem. Many men still blissfully resume that if their libido is normal , this automatically means that their fertility is fine , and that they do not need to check their sperm count.

By default, it is usually the gynecologist who then becomes the primary care physician for infertile couples. Unfortunately, most gynecologists are clueless about male infertility. Many have never examined a man in their entire professional career . They usually ask for a semen analysis; and if this is abnormal, they refer the man to a urologist. However , sometimes they do not interpret the semen analysis report properly , and this causes its own set of problems. For example some gynecologists still believe that a count of less than 60 million is abnormal – which means that men with a completely normal semen report are overtreated with medication , wasting valuable time.

What happens when the infertile man is referred to the urologist ? While the urologist is a specialist , many of them do not have a special interest in treating the infertile man; and there are very few specialised andrologists ( male infertility specialists). This is why many urologists continue to provide many ineffective tests and treatments for the infertile man. They will often try empiric medical therapy to improve a low sperm count; and because this rarely works, patients get fed up and frustrated. The trigger happy urologists diagnose a varicocele for practically all men referred to them, by doing a color Doppler ultrasound scan. Once they find a varicocele , they are happy to treat it – and when this doesn’t help to improve the patient’s fertility status, they throw up their hands and say – Sorry – there is nothing else we can do ! The other problem with a referral to a urologist is that the care of the infertile couple gets fragmented. Often the gynecologist has no idea what the urologist is doing , and vice versa, which means the couple is not treated as a unit. This often causes them to lose confidence in medical treatment.

Another weak link in the medical system is the fact that many laboratories do not know how to perform a semen analysis properly. Since it is such a cheap test, they often do it badly, resulting in wrong reports – and therefore , the wrong treatment.
Compounding this problem is the underlying fact that the basic sciences understand very little about male infertility. We really still don’t know enough about normal sperm production; and since we cannot pinpoint what the problem in sperm production is in the infertile man , there is very little effective treatment we can offer him. This is why the standard treatment for a man with a low sperm count today is ICSI ( intracytoplasmic sperm injection, www.drmalpani.com/icsi.htm) – a treatment which is conceptually crude, but works amazingly efficiently. We still do not have good tests for analyzing sperm function, so that a lot of our treatment consists of bypassing problems , rather than identifying them and solving them. This is a sad testimony to the fact that the infertile man has been relatively
neglected !

About 15 years ago , it was felt that strict morphology testing using Kruger criteria would help us to identify which infertile men had functionally competent sperm. Unfortunately , we now realize that these criteria are not always reliable. The new generation of sperm function tests are supposed to check for DNA integrity. Unfortunately , these are equally unreliable, even though they are presently very fashionable. This is because while they do generate valuable information in research studies, they are not very good at providing clinically useful information for the individual patient. Thus , while we know in general that infertile men will have higher sperm DNA fragmentation levels than fertile men, there is no number at which we can tell the infertile man whether or not his sperm are capable of fertilizing his wife’s eggs.

This sad truth is that male infertility treatment still leaves a lot to be desired. And this is why , ironically , the most effective treatment for the infertile man it to treat his fertile partner !

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How your doctor can reduce your fertility – a guide from Dr Malpani

Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here’s a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a “minor” surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to “clean the uterus”, thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor “improves” the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It’s only in India that doctors use this technique for “treating” infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is – and will often reflexively treat men with what they think is an “abnormal sperm report”. There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels – and doctors are quite happy to “fix” the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential – and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an “epidemic” of uterine TB in India – especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli – without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at http://www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that ” you need just one sperm to fertilise an egg”, it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer – and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low – its often that the sperm are functionally incompetent – and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it’s being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It’s true that a laparoscopy allows the doctor to also “find” adhesions and endometriosis, but making the diagnosis of this ( or “treating” them ) does not really improve the patient’s fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively “treat ” this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary – and does not improve the patient’s fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, “treating” the endo with meds just wastes the patient’s time – something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today’s high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to “diagnose” small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has “reported” his “diagnosis”, the patient often panics ! The doctor is happy to point out these abnormalities – and convinces the patients that it is these abnormalities which are the cause of her infertility – and that once these are “treated”, she’ll get a baby quickly ! What’s worse is that it’s easy to do the surgery with a laparoscopy ( which is just “minor surgery”), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What’s worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests – and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests – and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

The message is simple – if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at http://www.drmalpani.com/malpaniform.htm and I’ll be happy to help !

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.