Thursday, March 14, 2013

What went wrong ? Why did the IVF cycle fail ?

When an IVF cycle fails , the first question the patient asks the doctor is  : What went wrong ?

This can be quite an irritating question for the doctor because the reality is that even in a perfect IVF cycle , where everything goes right , the success rate will be less than 50 percent. However, when the patient chooses to phrase the question in this particular manner, it suggests he is implying that the doctor was incompetent ; or negligent ; or did something incorrectly ; or wasn't proficient enough. This upsets the doctor and sometimes doctors start getting defensive. Rather than giving the honest answer that we do not know why one particular cycle succeeds and why another one fails , they will order a battery of very expensive tests , to try to pacify the patient that they are on a quest to find the answer to this unanswerable question.

Mature doctors will sit down and explain to patients that we really don't have the technology to determine what happens to the embryo after we transfer it into the uterus. This is hardly surprising,  given the fact that we are transferring a microscopic ball of living cells inside the uterus. Human reproduction remains an inefficient enterprise , whether it’s being assisted in the clinic, or whether it’s being done in the bedroom.
However , not all patients are mature enough to understand the limitations of medical technology and science. Rather than explain the limitations of our science , it's much easier for the doctor to order a battery of tests. This often pacifies the patient , who thinks that now the doctor is on the right track ; and once she has figured out the abnormality and treated this, she will achieve success.

This is delusional thinking. After all , if there was a test which could provide this information , then every sensible IVF doctor would do it before starting the first IVF cycle itself. Why would they wait for failure to order the test ? After all , we don't want any of our patients to fail ! I’d be very happy if all our patients got pregnant in the first cycle itself. These happy patients would refer lots of other patients to me, keeping me extremely busy - and I would not have to answer questions such as – Doctor, What went wrong ?

However, because patients aren't willing to listen to the truth , doctors sometimes resort to manufacturing answers. This is actually a disservice to the patient , who ends up wasting a lot of time and money chasing red herrings , and not getting any closer to their goal of having a baby . Patients need to do their homework  before starting IVF, so that even if the cycle fails , they don't go to pieces and start looking for a scapegoat. They need to understand that even if nothing goes wrong, not every IVF cycle will end in a baby !



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6 comments:

  1. Doctor,

    Wanted to know the difference between EIA and ELISA method to determine AMH.

    Reason is ..
    2 labs have given AMH with EIA method as 0.47 and 0.6
    1 lab has given AMH as 2.6 with ELISA method.

    which one is correct ... dont know .. can u help us;.

    ReplyDelete
  2. EIA and ELISA both refer to the same technique - Enzyme Likned Immuno Sorbent Assay/ or Enzyme Immuno Assay !

    The variation in results could be because they used kits from different manufacturers to test the AMH level.

    In any case, the AMH test is a very new test, and it's reliability is still unproven.

    Can you please test your antral follicle count by doing a vaginal ultrasound scan ? Read more at www.drmalpani.com/afc.htm

    ReplyDelete
  3. Anonymous9:18 AM

    Doctor,
    If I have a failed cycle, I want to know why it failed, and this is a reasonable question, especially when a cycle costs about 10,000 bucks (give or take, depending on protocol). My Dr may go on the defensive, yes, but I just lost perhaps my only chance of having a child, unless I can secure some amazing financing, forego a nice car or a better home...

    To all IVF Drs, when your patient asks you this, we know you tried your best, but we do expect extreme compassion, and you may have to swallow your pride - your treatment failed, and we need answers. Nothing happens "just because." Everything happens for a physical reason.

    Was is a genetic issue? An undetected immune response? A lab error? Poor response to stims?

    If your patient asks for autoimmune tests, do it. Each failed cycle can further exacerbate immune issues, which could have been detected and resolved for the next cycle. I hope IVF Drs consider how devastating a failed cycle is, both emotionally and financially, and know that we aren't able to prepare ourselves for the worst and then shrug off a failure without question.

    ReplyDelete
  4. Thanks for your thoughtful comments. Failure can be devastating for the patient - but it hurts the doctor as well ! We all want our patients to get pregnant and "live happily ever after" !

    Yes, it's true that everything happens for a physical reason, but if we do not have the technology to determine the reasons accurately , should we send our patients off on an expensive wild goose chase ? This is just adding insult to injury !

    It's easy for doctors to order tests - but don't delude yourself into thinking that more tests = better medical care ! More is not always better - and looking for "immune abnormalities" just wastes time and money as we end up "treating" red herrings.

    Yes, doctors need to be compassionate - but this does not mean that they need to provide incorrect answers by doing the wrong tests !

    ReplyDelete
  5. Anonymous9:13 AM

    After a failed cycled- I was devastated. Like stated earlier it costs a lot. Our dr didn't even bother to schedule a follow up app to discuss the next option. We had to see his assistant - who had the gall to ask 'why did u do ICSI in the 1st place!!!' He didn't even read the file. I think that is pure incompetence and the dr should not be allowed to prac as he goes against every oath he took. Very angry-its 1 year later and it still hurts everyday!!!

    ReplyDelete
  6. Yes, I can understand why this hurts. A lot of patients feel abandoned by their doctor when the cycle fails. They feel that the doctor was only interested in earning his fees. Many feel bitter and cheated and refuse to seek further treatment because they feel betrayed.

    Did you ever write a letter to the doctor to air these issues ?

    Please don;t carry this bitterness in your heart - it will just make it much harder for you to move on !

    ReplyDelete

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