How relatives add stress to the infertile couple's life

Why infertile couples fight over sex

How email improves doctor-patient communication

Many doctors are worried that email will ruin doctor-patient communication, because they feel that face to face interaction is vital to preserving the doctor patient relationship.

Actually, for established patients, email is a far better way of communicating with the doctor, as compared to a phone call.

I find that patients are quite reluctant to phone a doctor with their "minor doubts" because they do not want to disturb the doctor. This means that a lot of worries remain unresolved. With email, on the other hand, they are much more willing to ask for clarifications, because email is much less intrusive, and they know I can answer at my convenience ! Email allows me to provide reassurance and comfort much more easily to my patients.

My replies can be thoughtful and reasoned - and because I am not rushed ( as I might be in the clinic when I have lots of patients waiting to be seen), it is actually easier for me to be more empathetic by email !

Interview with IVF specialist, Dr Malpani

Does computer use in patient-physician encounters influence patient satisfaction? -- Lelievre and Schultz 56 (1): e6 -- Canadian Family Physician

Does computer use in patient-physician encounters influence patient satisfaction? -- Lelievre and Schultz 56 (1): e6 -- Canadian Family Physician: "It was hoped that the introduction of computers and electronic health records into medical practice would revolutionize medicine, improving quality of care and patient satisfaction. Electronic health records do bring with them many benefits, including easy access to legible notes, prescription-writing systems, drug interaction systems, and, in some cases, laboratory and imaging information. Other demonstrated benefits include greater adherence to preventive care guidelines and a decrease in the cost of care in the long-term. However, apart from the obstacle of the initial investment (it is estimated that it would cost a total of $18.7 billion to create an appropriate Canada-wide electronic health record system), physicians have numerous concerns regarding electronic health records. These include security, time-effectiveness, loss of eye contact, and negative effects on patient-physician relationships."

Many doctors ( esepcially the older generation who is not adept at using computers) will roll out many excuses as to why they don't need computers to practise good clinical medicine. In fact, some of them claim the computers will harm the doctor-patient relationship as the doctor will spend more time with the PC than with the patient. This study is very reassuring - and shows that patients actually prefer doctors to use an EMR. It gives patients confidence that the doctor is well organised; and that their medical records are well documented and safely stored !

Two suggestions I give young new doctors who are just starting practise are :
1. make sure they have a website; and
2. use an EMR.
This will be their USP and will help them to stand out from their seniors and the rest of the competition !

Knowing we practise good medicine: Implementing the electronic medical record in family practice -- Dawes and Chan 56 (1): 15 -- Canadian Family Physician

Knowing we practise good medicine: Implementing the electronic medical record in family practice -- Dawes and Chan 56 (1): 15 -- Canadian Family Physician: "We aim to be good physicians, providing safe and effective care to our patients. But is that really the case? Family physicians deliver care through the process of our practices and the method of our consultations. To understand what sort of doctors we are, we need to evaluate both aspects of care. Your initial response is probably scepticism or disbelief. You don’t have the time or the energy, and even if you did—so what?

We would be concerned if half our patients with hypertension had systolic blood pressures greater than 160 mm Hg; if our patients with suspected herpes zoster had no way of seeing us within 3 days; if we ordered a blood test, urine test, or x-ray scan at every consultation; if we didn’t listen to patients; or if we finished every consultation by pushing a prescription at the patient. We don’t believe these things occur, but how can we be certain? To make sure we provide good quality medical care, we need electronic records."

Top 50 Healthcare IT Blogs

Top 50 Healthcare IT Blogs: " So many great blogs about healthcare IT exist, but — unfortunately — many of them are not updated on a regular basis. This point is important for blogs that deal with an ever-changing field. This is one point we considered in the following list of top fifty healthcare IT blogs…the other points we considered were relevant information along with a good following and a well-written and easy-to-comprehend blog."

The Patient's Doctor is proud and pleased to be part of this august company !

A UK success story - from the heart !

Since both of us moved to UK after marriage, the settling down process took its toll and we initially felt that this stress was the main factor obstructing us in our progress towards having kids? Meanwhile, we resorted to medical aid in UK despite a lot of financial hardships. We had 2 IUI attempts and one abandoned IVF in UK with no success. The infusion of so many hormones and the stress of maintaining a job had its toll on me emotionally and my relation with my husband got affected-I had mood swings, bouts of depression etc. After another year, my husband started thinking of adoption. I was not averse to the idea myself. In fact, I wanted to have a baby of each race in my house; they all have their unique beauties. But my great faith in medicine was not ready to accept the fact that we can’t have our own kids when we both were medically fit. I knew that my biological clock was almost dying but why rob my husband of the joy? So I started scanning the internet and zeroed in to two Doctors in India.

I chose India because I am still an Indian at heart and there was definitely less Red Tape. Moreover, I knew that I would have to take an egg donor and the legal system in India allowed anonymity of the egg donor for life time unlike UK where the child has the right to know the donors at a later stage.

No doubt, we were initially very hesitant to get any treatment in India mainly because of lack of secrecy and a broad understanding on the advances of medicinal science from family. We were not confident about how good the Indian medical professionals may be though they have made quite a niche in UK and USA. As you know bad news travels faster and influences a person more. However, the doctors in UK informed me that there was nothing wrong with my reproductive system or with my husband’s and that it was a matter of time when God would bless us.

The two doctors chosen by me were Dr. N, and Dr. Aniruddha Malpani, Mumbai. I emailed both the doctors. I had to remind Dr. N to respond to my emails on a very bad mobile network whereas Dr. Malpani replied the very next day.

Dr. N simply said,’ Come over, we can do it.’ I was aghast; how is it possible without asking any preliminaries like my age, my physiological state, medical updates or reports etc. I had also put an enquiry on Dr. N’s website that was picked up by some agent of theirs in UK who dealt with European queries due to language problems. However, my sixth sense said, NO.’

I was very impressed by Dr. Malpani’s responsive behaviour and professional attitude. I sent him umpteen queries to which he responded with all patience. I even asked him point blank why he was more expensive than others and I liked his confidence when he replied that he knows that they are the best. We planned each and every thing in great detail as we had very limited time. Because of all this planning, I was able to traverse practically all the four corners of India with my other engagements within four weeks without affecting my treatment. This was possible because I was able to contact Dr. Malpani by email or by phone wherever, I was and also kept sending him my results whist on his monitoring schedule. And if he was busy, he ensured that he returned my call or responded by email. Hats off to technology and the professionals who know how to use it in the right way!

I arrived in Bombay in the last 10 days of my Great India tour and was joined by my husband. Dr. Malpani had everything under control-my tests were coming fine, the donor was ready and my husband was in time.

Finally, the eggs were retrieved. There were 12 eggs. Three fertilised healthy embryos were then transferred into my uterus . I felt great being part of such a marvel in medical science.
Dr. Aniruddha Malpani and his wife Dr.Anjali Malpani, the embryologist, Dr Sai and the whole team of nurses and receptionists were very supportive. While transferring the embryos, Dr. Malpani asked me,’ which god are you praying to?’ However, I was too elated to pray at a time when I knew that a miracle is being performed and at that time I was more aware of the messenger of God-Dr. Malpani, than God himself. I knew that we would succeed. On reflection, I realised that actually I do believe in God as a power but I have not been able to give any particular name or face to any of the gods. I believe in all religions and specifically in Humanity and the doctor was the epitome of that. I had a few hours rest at the clinic. That night I dreamt two embryos were floating down into my body and nestling comfortably in my womb. So much for wishful thinking! I told my husband the next day and he brushed my talk aside saying,’ Just leave it to God. At least we tried.’ May be he was too scared to even think positive after all that we had gone through all these years. We flew back to UK after 3 days of the transfer. But I must say that though we had been on holidays before this one was the most relaxed and enjoyable holiday I ever had in my whole life. No family/relative obligations, no dinners to attend to, and no work obligations. We would get up in the morning leisurely and then hit the few selected restaurants for lunch, watch movies in theatres or walk around Taj and then come home late after dinner like we used to do in our courtship days.

Back at home in UK, we had to wait 14 days before I could go for a HCG blood test to confirm my Million Pound lottery and that day fell on a weekend and the surgery was closed. So my husband bought a Pregnancy test and I tested with baited breath and saw the blue line appear like a boon. It was unbelievable. In my previous tests I had thought that this Blue line never ever shows but there it was right in front of my eyes!!!

Further blood tests followed and then an early ultrasound confirmed that I was carrying twins. I had few problems initially with bleeding and lots of weakness that was well looked after by doctors in UK. All is going on fine now. My twins have started kicking-one is a quite one with gentle kicks while the other seems a bit aggressive-good complementary personalities, it seems! I am just praying for all to go well am eagerly awaiting the arrival of new joys in the family.

My advice to all those couples who are planning to go through medical treatment is that it is no use wasting time and money in IUI, if you really want a child, one should go for IVF straightaway. And no doubt, I would highly recommend Dr. Malpani and his team in Mumbai, India.

Accelerating Innovation In Information And Communication Technology For Health -- Crean 29 (2): 278 -- Health Affairs

Accelerating Innovation In Information And Communication Technology For Health -- Crean 29 (2): 278 -- Health Affairs: "Around the world, inventors are creating novel information and communication technology applications and systems that can improve health for people in disparate settings. However, it is very difficult to find investment funding needed to create business models to expand and develop the prototype technologies. A comprehensive, long-term investment strategy for e-health and m-health is needed. The field of social entrepreneurship offers an integrated approach to develop needed investment models, so that innovations can reach more patients, more effectively. Specialized financing techniques and sustained support from investors can spur the expansion of mature technologies to larger markets, accelerating global health impacts."

I completely agree ! This is why I am an angel investor in startups such as Plus91 which will use IT cleverly to improve health care in India !

Cell-Phone Medicine Brings Care To Patients In Developing Nations -- Feder 29 (2): 259 -- Health Affairs

Cell-Phone Medicine Brings Care To Patients In Developing Nations -- Feder 29 (2): 259 -- Health Affairs: "At the Mexico City HIV clinic, Carlos has seen these mobile health tools transform HIV/AIDS care for himself as well as for new patients starting treatment. With VidaNET, he says, patients 'have more power' to drive their own care and convey their concerns to doctors. In fact, it’s not too much of an exaggeration to say that e-health could help to bring about a 'democratization' of illness in countries like Mexico—now that access to much of the world’s medical expertise is increasingly just a text message away."

We need lots more success stories like these ! The cost for innovation in places like India and Mexico is much less than in the US, and the impact of these innovations is far more because they can reach out to so many more people !

E-Health Technologies Show Promise In Developing Countries -- Blaya et al. 29 (2): 244 -- Health Affairs

E-Health Technologies Show Promise In Developing Countries -- Blaya et al. 29 (2): 244 -- Health Affairs: " Is there any evidence that e-health—using information technology to manage patient care—can have a positive impact in developing countries? Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted."

I believe that a lot of the e-health innovations will come from the developing world. Mobile penetration is very high here; and there just aren't enough doctors to go around, which means the demand and the need for clever e-health applications is far greater !

Surrogacy - making sure we do a good job !

There is no question that surrogacy remains one of the most complex issues society faces today. While it is an effective way of helping some infertile couples to have a baby, it raises a number of complex ethical and legal issues which we have still not been able to tackle effectively.

How do we ensure that infertile women who do not have a uterus can use surrogacy treatment to have a baby , since this is the only medical treatment option available to them ? How can we ensure that poor infertile women are not coerced or exploited into becoming host wombs ? How can we make sure doctors provide surrogacy treatment only to couples who actually need it ? How can we resolve the challenging issues of genetic parenthood and social responsibilities ? And how do we resolve the rights of the genetic mother versus the birth mother if there is a dispute ?

Some countries have taken the easy way out and just banned surrogacy outright. I think this is unfair. Why should a woman who does not have a uterus, and who can have her own baby with the help of surrogacy, be deprived of the chance to use this option ? In fact, I would go so far as to say that it is unethical to ban surrogacy, because this encroaches on an individual’s reproductive autonomy.
Let’s look at some of the simple situations first, before we move on to the more complex ones.

Most people would be quite comfortable with allowing a sister to be an altruistic surrogate for a woman who does not have a uterus, if she is comfortable doing so. This means that most people are not averse to the idea of surrogacy itself , if it’s done properly and helps infertile couples to have the children they desire. Similarly if a woman who already had kids agreed to be a surrogate for an infertile woman who could have carry her own babies, most people would not object.
The problems start cropping up when we talk about commercial surrogacy, because money is now changing hands. Once money enters a transaction, then things become much murkier. Why is this so ?

In reality, there’s nothing wrong in paying someone to being a surrogate . Just because someone agrees to become a surrogate for money does not make this unethical. As long as all parties involved understand what is involved and are happy to take part, this is fine. After all, it is a voluntary transaction between consenting adults, each of whom is choosing to participate.
So when so eyebrows start getting raised ? It’s when clinics start taking shortcuts and arranging surrogates purely for commercial considerations, without considering what’s in the infertile couples or the surrogate’s best interests. The tragedy is that this is going to become increasingly prevalent because of the ICMR guidelines, once these become law.

This is because the ICMR has put the burden of sourcing and counseling surrogate mothers onto commercial agencies. Unfortunately, while the ICMR Rules have strict guidelines as to what an IVF clinic needs in order to be recognized and registered, there are no guidelines for who can be a surrogate agency. This means all kinds of agents, middlemen and fixers are crawling out of the woods today , and approaching IVF clinics, offering to “find” surrogates for them, so that they can make a quick buck. Most doctors are too busy to care – and are quite happy to turn a blind eye, as long as they can continue treating their patients. They feel that looking after the surrogate is the agency’s job, and do not critically examine how the surrogates are counseled or looked after.

This is a shame, because it allows all surrogacy arrangements to be viewed with a jaundiced eye. Unethical surrogacy agencies will use pimps to hire prostitutes to become surrogates; while other swill confine 10 surrogates to live in a single room, away from their own children , for the duration of the pregnancy. Once these kind of unsavoury arrangements come to public notice, there will be a hue and cry – and the standard knee jerk reflex will be – Ban surrogacy !

What about the activists who claim that surrogacy allows people to treat babies as commodities; or that surrogacy is just a kind of prostitution, where the woman is selling a part of her body for financial gain. I feel this is an unfair criticism. Infertile couples resort to surrogacy to have a baby only after a lot of soul searching . It is never a “spur of the moment” thoughtless impulse decision – and the babies born as a result of surrogacy treatment are deeply loved and cherished. Is the surrogate “selling” her womb ? Again, I think this is unfair. Just because a woman is poor does not mean she is stupid – and as long as she understands what she is doing and does this of her own free will, she should be allowed to exercise her freedom to do so. This is far better than having a professor who lives in an ivory tower dictating what she is allowed to do – and what she is not, just because she is poor !

I agree that the present system leaves a lot to be desired. It is broken and it needs to be fixed urgently ! What’s wrong with it ? For one, it’s open to a lot of abuse and misuse. Let’s look at these one by one

1. Overtreatment. There’s no doubt that surrogacy is overused, misused and abused. Infertile couples are often fed up and frustrated – especially when they have failed multiple IVF cycle or suffered from many miscarriages. They are depressed and disheartened – and feel that surrogacy would be the perfect option for them. Little do they realize that surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. Research shows that the reason for failed implantation is much more likely to
be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem; and that embryo adoption or egg donation would be a far better solution for them. However, they have low self-esteem are often not capable of thinking critically – and when a doctor offers to do surrogacy treatment for them, they feel this is the best solution for all their problems, as it bypasses all the hurdles mother nature has created for them. So why do doctors suggest surrogacy for them ? Unfortunately, the reason is purely commercial – for the sake of money. Doctors can charge much more for surrogacy treatment, as compared to the simpler options, so most of them are quite happy to do so, without discussing simpler ( and less expensive) options ( which may actually be better for the patient) with them.

2. Dishonesty. Because there is very little transparency in most of these surrogacy arrangement, many unscrupulous doctors take undue advantage of this by lying to their patients. There are doctors who tell the patient that the treatment worked and that their surrogate is pregnant after the embryo transfer ; collect the balance payment due – and then tell them that she unfortunately miscarried at 8 weeks of pregnancy ! It’s very easy to take these patients for a ride, because there is no documentation – and there is no way the patient can verify or dispute these claims. The poor patient is completely dependent on the doctor’s honesty and professionalism – and unfortunately, not all doctors are upright.

3. Secrecy. Because most clinics prefer being very secretive and hush-hush about surrogacy treatment ( and I always wonder why ? After all, what do they have to hide ?) it’s often the sad reality that the middleman siphons away most of the money, and the surrogate gets only a pittance. This is exploitation – and it must be prevented

4. Poor documentation. The surrogacy treatment paperwork today leaves a lot to be desired. Lots of doctors don’t even bother to do it – while others fudge it or do a bad job. This can create lots of potential problems – some of which have become headline grabbers already, as in the Baby Munjee case.

Surrogacy is a complex process , because it involves multiple players, each of whom may have different interests . It is this complexity which leads people to believe that it’s not possible to streamline this process. It’s stupid to take an ostrich in the sand attitude and pretend that the problem does not exist. It’s far better to address this proactively, so we can prevent problems from arising !
What we need to do is to look for solutions ! I’d like to propose a very simple cost effective solution which can be easily implemented , at no additional cost, and which will help to keep everyone happy.

The solution is this - only adoption agencies are authorised to provide surrogates. Adoption agencies have experience and expertise in family building – and in dealing with infertile couples; doctors; lawyers; and babies ! Also, it helps to reinforce the idea that surrogacy and adoption are complementary option, not competitive, because the adoption agency can offer them both options. Moreover, the money earned on the surrogacy treatments can be used to promote adoption as well. In this model, the doctors are only treatment specialists – as they should be !

How would this work out in real life ? The infertile couple who wanted surrogacy would approach an IVF specialist, who would evaluate their problem and decide if they needed surrogacy or not. If he thought they did, then he would contact the adoption agency and ask them to organize a surrogate mother for this couple. The couple would then go to the adoption agency with this referral note; and would put their name down on the surrogate wait list. The adoption agency would have an active surrogacy recruitment program, where they would screen and counsel prospective surrogate mothers, to decide if they were good candidates for this. The agency would then match up the couple with a surrogate; collect the fees which would be placed in an escrow account; and use their in-house lawyer to sign the surrogacy agreement contract. Armed with this, the infertile couple and surrogate would go back to the IVF clinic, where the doctor would perform the IVF treatment. Once the surrogate got pregnant, the doctor would then refer her back to the adoption agency. The agency would then ensure that she got excellent prenatal care from an independent obstetrician; and home visits to her house would ensure that she was taking good care of herself. After the baby was born, the agency would ensure that the intended parents’ name was placed on the baby’s birth certificate; and handover the baby to the infertile couple. This would ensure that most loopholes are plugged and that surrogacy treatment is performed properly.

The adoption agency thus plays a very important role in this process, and makes sure that the counseling, the legal paperwork and the payments are all performed properly ; that the surrogate is protected and looked after well ; and that after the baby is born, the right baby is handed over to the right infertile couple. This way, the doctor focuses on his core competence – doing the IVF – while the rest of the non-medical tasks are performed by the adoption agency. Infertile couples are much happier that the process is transparent and open; and society is reassured that surrogacy is performed ethically and correctly, and that exploitation and misuse is being prevented.

This way, the complex process of surrogacy is broken down into its individual pieces, each of which is performed by the organization which is best suited to doing so.

What role does the judiciary play in all this ? It is important to have regulations laid down, which will authorize only adoption agencies to provide surrogate mothers to IVF clinics. Also, since most surrogacy arrangements will sail through smoothly, no judicial intervention will be needed ordinarily, thus preventing an additional burden to our already overstrained courts. It’s only if and when disputes arise that we will need to take recourse to the courts.

Even more importantly, it’s a fact that the law has not been able to keep up with reproductive technology – and this will always be a problem with all laws and regulations . The involvement of social workers will ensure that advances, as and when they occur, will be utilised sensibly, keeping the best interests of everyone - the infertile couple; the surrogate and the baby in mind ! Allowing social workers to provide oversight is effective. They are trained professionals who will be motivated to perform efficiently.

With this system, transparency is encouraged, which will prevent exploitation. Good clinics will set the benchmark , and others will be forced to follow suit. Thus, if the clinic routinely shows photos of embryos to the patients, this will soon become the norm for all surrogacy clinics !

Equally importantly, this system protects everyone. Infertile couples are happy that their surrogate is being looked after well; surrogates are fairly compensated; and doctors can focus on improving their medical treatment and pregnancy rates, since the paperwork is taken care of by the adoption agency.


What do we do when things go wrong ? Yes, they will – but the reality is that things go wrong only when the surrogacy treatment is not done properly. The chances of problems arising when it’s done properly are low.

What’s the danger of leaving things as they are ? The biggest danger is that the present guidelines encourage the establishment of “for-profit” commercial surrogacy agencies. While some of these will be run by ethical professionals, the danger is that a few bad apples will take unsavoury shortcuts to make a quick buck – and the resultant bad press will end up harming everyone – good IVF clinics; and infertile patients who need surrogacy as well. All IVF doctors will be painted as villains, who are willing to go to extremes, just to make a quick buck.

Is this going to be a panacea for all problems ? Of course not ! I understand that adoption agencies can often be bureaucratic organizations which get bogged down in paperwork. And there will be some unethical and incompetent social workers as well ! It’s just that having adoption agencies actively involved in the process will help to prevent lots of problems. Problems primarily arise because of poor patient selection; inadequate counseling of surrogates; poor surrogate selection; lack of transparency; the presence of legal loopholes; and the involvement of “for-profit” unregulated middlemen who subvert the process and exploit patients and surrogates for money. Since adoption agencies are non-profit bodies, who employ social workers who are skilled in counseling and family building; and are used to dealing with lawyers and infertile couples, they offer a perfect solution to this problem. The beauty is that no additional organizations would need to be created to tackle this onerous problem – we would just have to make more efficient use of the existing organizations. Even better, the money which adoption agencies make from these surrogacy arrangements could be used by them to take better care of the abandoned children they put up for adoption; and to promote their adoption efforts as well !
The problems surrogacy presents are not unique to India – they are present all over the world ! It’s just that India today has a great opportunity to create a smoothly functioning system which can serve as a model for the rest of the world !

What is a Man with a Low sperm count supposed to do ?

Why the treatment of male infertility can be so confusing and frustrating