Tuesday, July 8, 2014

My overall review for Dr. Malpani

One has three basic requirements of an IVF clinic:
1) that they design a good protocol, either for an IUI or IVF. This protocol can (and should) be tailored to fit your medical history.
2) that they perform the retrieval and transfer competently
3) that their embryologist is competent

Then there are the minor points that contribute to the overall picture: How are the nurses? How is the attention of detail of both the doctors and the nursing staff? What is the sensibility of the doctor?  What is their honesty/fairness level, medically and financially?

Let us start off with what the Malpani Clinic does right.
  • Retrievals and Transfers: Both the transfer (by Dr. Aniruddha Malpani) and the retrieval was done by Dr. Anjali Malpani were competent and well done.  From all accounts (my mom was in the OT with Dr. Anjali Malpani when she was doing the retrival), she is very competent and thorough. I also thought she has a pretty good bedside manner when she was doing the scans. 
  • Embryology: While their attention to detail I certainly found lacking, from all accounts the embryology lab is competent; I had no cause for complaint overall. My embryos grew well (in the second round), and survived the freezing and thawing. 

Moving on to the issues 

Poor protocol design, and  not a great understanding of biology: When I first came to the Malpani clinic, I relied on him to design the protocol. His choice of protocol for me was the micro-dose lupron protocol. I remember being surprised by this: when we sat down during our initial discussion, and I assumed we would start BCPs that cycle (as in the long agonist protocol) and start the stims the next one. He told me, no need for that, come back when you start your period, we will do an ultrasound and start lupron and the stim drugs then. Like an utter idiot, I trusted him and liked the thought of avoiding BCPs and many injections and did no research. At that point, I had not bothered reading up and understanding IVF, and I did not know then, as I know now, that this is usually picked for poor responders or women with a DOR.

Long story short, the protocol he picked fried my eggs. My response to it was horrible. I became convinced I was a poor responder, and was so lost and confused because I had not expected to be one, given the fact that I got so pregnant so easily on unmedicated cycles, with great progesterone and beta-HCG values.

Some of the issues in the protocol were evident to me immediately, and later, when I talked to two other doctors (Dr Sher and Dr Bohrer at RMA-NJ) and both of them showed surprise that this protocol had been picked for me  and mentioned that their approach would be very different. After I read up on IVF and understood it well enough to design my own cycle, I came to the conclusion that yes, the microdose lupron protocol should almost never be the one to start with, especially in younger patients with good AFC/AMH levels: it could be tried after the somebody does badly with the two traditional protocols (long agonist and antagonist).

As a note, I do not hold him responsible based on the result of the IVF, I hold him responsible for the poor choice he made. If he had picked either of the logical choices (long agonist or the antagonist) and things had gone badly, I would never have held him responsible, because there would have been nothing wrong with the decision he made. But the microdose lupron protocol for somebody like me? Abysmal, incomprehensible choice. And boy, did I pay for it. I was not a poor responder, but the protocol Dr. Malpani picked for me made me a poor responder. What I lost here: time and money, and not to forget the emotional turmoil I went through. Trusting him blindly, like a normal patient trusts their doctor, cost me greatly.

Other things also bothered me was his usage of menagon, especially at high doses (300-450). Menagon contains equal amounts of LH and FSH. Now, if you give somebody 450 IU menagon, they are getting 450 IU FSH, but they are also getting 450 IU LH every day.This is very unlike the natural cycle, where LH stays low throughout, and then peaks just before ovulation. In my opinion, this is ill-advised, because different people have different sensitivities to LH. Many people can tolerate it, but for some others, their egg quality may be better if you give them follistim with very low doses of LH. In some people (especially those with PCOS), more LH may be detrimental. His protocol ensured I got a large blast of pituitary LH on day 2/3 when he started my lupron, and then followed it up with lower amounts of LH from the menagon he had me on. When I applied the theory that increased LH was the problem while designing my own protocol (all I did was to ensure that the LH was low until just before ovulation), my response was superb. That was all it seemed to take for me to go from a very poor responder to an excellent responder. Yet, when I put forth all of this to Dr. Malpani, he showed a total lack of receptivity to the point that LH should be high only at certain points in the cycle, not throughout. This also reinforced my opinion that his grasp of biology is less than what it should be.

Another very important reason that many big-name doctors seem to avoid menagon: This is FSH and LH extracted from urine, and there can be batch-to-batch variations. During my first cycle, I remember the Malpanis remarking  that they were seeing excellent results because this batch was so potent. Later, when all the pieces fitted together in my head, and I found the mentions of doctors avoiding menagon because of the batch-to-batch variation, I remember thinking: what about the poor saps that get a less potent batch?

One of his questions drove home the fact that his understanding of cell biology, and biology in general, is rather rudimentary: He used to ask my opinion on a lot of things, and one day, he asked me across the curtain post ultrasound: why on earth do people use Coenzyme Q10 to improve their egg quality? It has nothing to do with the eggs after all. At that point, I was really preoccupied and just mumbled a  vague response. However, when I thought about it later, I pondered the fact that he had asked this, and was appalled, because it reflected a lack of understanding of cell biology, which an RE should have, given that their speciality is eggs. You would need to have a basic understanding of cell biology get the connection between mitochondrial health, its possible decline with egg aging and the connection between mitochondrial efficiency, free radical production, chromosomal division, and the eggs ability to multiply and be fertilized after. Sigh. For anybody who is interested, here is the take from an RE who DOES understand the theory behind this.

So overall, from what I have seen of Dr. Malpani, his understanding of biology seems to be in very broad strokes, while missing most of the subtleties. And, in my opinion, based on the fact that he picked the microdose lupron protocol for a patient like me, his judgement is highly questionable.

Lack of attention to detail: This guy is very high-energy, and while he is talking and his brain is jumping from topic to topic, he really does not seem to pay attention. I had told him, multiple times on multiple occasions, that I only wanted to do a single embryo transfer.  At no point in those conversations did he stop and tell me, well, we freeze our embryos in pairs. At no point did he note down my wishes and convey it to his poor embryologist. In an age where many forward-thinking doctors and clinics are actively encouraging their patients to go for a single embryo transfer, he heard my wishes and ignored them entirely, and forced me into a corner by freezing most of my embryos in pairs. I thought I could have gotten out of that corner by starting a cycle with two surrogates and transferring one embryo to each of them. When I told him this idea a long time ago, he did not tell me it was illegal, and we started a search for two surrogates, only to abandon it for other reasons later. The doctor at Surrogacy India later enlightened me that I had no chance of doing this.

Anyway, this point has become moot as this guy refused to transfer my embryos to another clinic and has destroyed (or is going to destroy) them instead(!!!!!!!!!!!!!!!!!!!!). Details in my other post.

Lack of thoroughness when screening the surrogate: When taking my surrogate's history, she told him that she had only been a surrogate once before. After I spoke to Surrogacy India during the pregnancy, I found out she had lied, and had gone through surrogacy twice before. I do not know what communication, if any, took place between him and surrogacy India, but If i had a surrogate coming to me, based on what I know of surrogacy in India, a large part of my time would be in verifying her past medical history. In this case, all he would have to do to check out her history would have been to pick up the phone and call SI.

Another thing that shocked me (and the two other doctors in the room when we found out): He knew she was Rh-negative, and his extent of investigation there was to ask if she had gotten the anti-D shot. This is to a semi-illiterate woman who does not know her own medication. To her, an injection is an "injection." He never bothered doing a simple blood test to make sure she was not immunized to the Rh antigen before implanting my incredibly precious embryos into her (I checked her file, there was no screening test for anti-Rh antibodies at the time of surrogate selection). If anything had happened and had she been immunized, my child would have been in very real danger.

Lack of basic medical ethics: Many of you may remember this, but Dr. Malpani, without asking my permission, decided to give a newspaper reporter my blog address. That reporter decided to put up my blog address in a newspaper article that was featured on the first page of the Times of India, which is the biggest bloody paper in the country. I asked two other doctors whether they would give a patient blog address to a reporter, and both said: "NEVER without clearing it with the patient first." I'd call this basic common sense.  He did not bother apologizing or even acknowledging anything after this incident.

Behavior during the pregnancy: As this pregnancy progressed, he became incommunicado and absolutely non-cooperative, and even obstructive in the end. The surrogate's pre-pregnancy TSH was 2.7. I wanted the TSH rested during pregnancy, and as an added precaution, I also wanted to have her tested for anti-TPO antibodies. He refused to do both tests, even though I was the patient and was paying for everything. He would not even draw blood for the TSH test. When I requested him for all the tests (TSH, T3, T4, anti-TPO): he emailed me to say  I am a RE. I cannot hence test for anti-TPO antibodies because it is not one of the tests we run. This was so utterly ridiculous,  because REs around the world routinely order tests for anti-TPO antibodies: my RE in San Diego ordered it for me, without my asking. Dr Malpani may not know this, but thryoid dysfunction forms a significant part of reproductive endocrinology.

He also made life utter hell for us during the last month of the pregnancy, and my daughter was born with an infection that looked like it started in utero. Details in this post.

Financial dealings: Major, MAJOR issues here, please see my other post on this.

In summary, for IVF, the Malpani clinic is a mixed bag.

In the plus column, he has a competent setup (as far as egg retrieval and the embryology lab goes) and is extremely approachable when you start, and can be easy to work with when he is not angry with you and trying to block everything you want: the second round of IVF, I designed my protocol from start to finish, and it was an amalgamation of many tricks and studies, and to give him credit, he put aside his ego completely and let me do it.

In the minus column, to me, he seems to be the weakest link in his own setup: my end impression of him was that himself is more of  businessman/showman who talks a good talk, but may not be able to design protocols very well, has poor attention to detail, and is definitely more financially unfair in his charges/dealings than others in a similar line of business (example, Surrogacy India). Additionally, as my experience proved, when unprofessional, he is really unprofessional (giving my blog to reporters, not responding to crucial emails, refusing to transfer my own embryos and sperm vials (!!!!!) to try to get me to pay a charge that was unfair and not specified upfront. He has emailed me that he has destroyed the sperm vials that I asked him to transfer (!!!). Unbelievable, and I don't think he realizes the amount of trouble I could have bought to his door for refusing to do this, or for not transferring my embryos, which could have been my children! Also...which doctor gives a patient's blog address to a newspaper reporter without clearing it with that patient first?

His equipment is also not very high end (ultrasounds on his rather ancient ultrasound machine provided conflicting reports from that from newer 4D  ultrasound machines, causing no end of confusion). He pooh-poohs embryoscope usage and was extremely reluctant to use PGD and CGH microarray analysis.

Should you go to him if you wish to do IVF plus surrogacy? I would really not recommend him based on my experience. Towards the end of the pregnancy, we were counting down the days before we could be free of him, and he would have no more control over my unborn child's care.

Should you go to him for IVF?  Up to you. His clinic may be better than a lot of the others in many parts of India, but it is definitely not ideal. All the things that are good about his clinic (good embryology lab, decent skills for retrieval and transfer) may definitely be found elsewhere as well in Mumbai alone. It is definitely possible that their charges may be more fair than that of this man, especially if you are paying in dollars. It is also possible that the protocol design skills may be better.

As a side note, I have heard some horror stories about medical ethics (the use of somebody else's embryo!!) coming from IVF clinics in delhi, so unless you have a personal recommendation or a very good reason to go to a Delhi clinic, know that you are dealing with a very unknown entity.

Here are two options in Mumbai that address,at a surface glance, some of the lacunae in the Malpani setup:

Dr. Pai at Lilavati Hospital: I went to him for a consult, and I administered a test of sorts: I gave him my history of easy pregnancies and loss and my AFC/AMH values, and then asked him what protocol he would start me on, and he said "Antagonist." That was the right answer, and to me, that definitely trumps Malpani in the crucial protocol-design department. Dr. Pai also was very gung-ho about PGD analysis by CGH microarray (he had the setup in place that I had desperately wanted at the time of my IVFs), and also pushed embryoscopy while doing Day 3 transfers, which to me makes sense. If you are going to do a day-3 transfer, just going by embryo morphology to pick the best embryo out of 10 or 12 embryos is foolish, when you can weed out a lot of the poorer candidates using an embryoscope, which obviously considers multiple parameters and can give you far more information than embryo grading. Very importantly, this can also reduce the number of embryos you have to transfer at one go, which may result in a less complicated pregnancy.

Dr. Pai also (very sensibly) refuses to handle any of the aspects related to Surrogacy, and outsources this to Surrogacy India.

Out of curiosity, I googled "Dr. Pai reviews" and could not find any red flags. This morning, I googled "Dr. Malpani reviews" and found a page addressed to complaints about this doctor. Sigh. I can only smack myself on the head so much.

Nova IVI: This is a branch of a Spanish Infertility clinic that now works in India, and has branches in many cities. I can only talk about the Mumbai branch since I met the doctors there. I did not quiz the doctor I met on protocols, so I cannot comment on that, but what this setup would offer is cutting edge technology. Their clinics provide the CGH microarray technology, and they also offer embryoscopy and the rather interesting Endometrial receptivity array test. Dr. Pai also pushed for the ERA test.

However, NOVA IVI is a huge setup across different cities: be aware that local doctors could influence how that clinic runs, so this may be more a wild card than Dr. Pai's setup. Google the doctor you will go with before starting.

Overall, Nova IVI definitely more bang for your buck than at the Malpani setup. Also, whatever technicians they have would be very skilled at embryo biospy if you were going for PGD testing, which is a pretty important consideration for me.

The Mumbai Nova IVI clinic also works with surrogacy agencies (SI as well as Little Angels). Like I said, there are few doctors who put up their own surrogacy website and claim to handle all aspects of surrogacy, while delivering what I had to endure. 


  1. I am so sorry the whole experience was so stressful. I hope people researching surrogacy in India find your review and are now able to make a more-informed choice.

  2. You have done a good thing by posting all of this information in such a comprehensive way. I am sorry you had to go through this all. I admire that you took the time to share your experience so others can have a clear view when making their choice

  3. Ironically - him passing out your blog address may have been the best thing. People will come and be warned about him, and hopefully avoid his clinic. There is a silver lining!