Wednesday, September 11, 2013

IVF success - luck or skill ?

IVF doctors , like all professionals, take a lot of pride in their skills and expertise . We spend years mastering the skills required to be able to do IVF, and most IVF doctors believe that they are better than their colleagues. ( Low self esteem has never been an issue for IVF specialists, most of whom have fairly large egos !)

While it is true that doing IVF well requires a lot of experience and expertise , it is equally true that the outcome of a particular IVF cycle is completely unpredictable . It depends upon a lot of factors along with the doctor’s skills. While the doctor’s expertise plays an important role in whether or not the cycle is successful, it’s also equally true that skill is necessary, but not sufficient . Any honest doctor will agree that luck plays an important part in IVF – after we have transferred the embryos into the uterus, we have no control over whether they will implant or not – we cannot control in utero biological processes. We have all seen patients who had no business getting pregnant, because their embryos were of poor quality, but who end up pleasantly surprising us ! On the other hand, we also have patients who cycles are perfect, but who stubbornly refuse to get pregnant, no matter how many times we try, and how often we tweak their protocol ( or how often they change their doctor).

The truth is that the outcome of an IVF cycle ( as is true for most medical procedures) is affected by many intangibles which we can call luck ( for lack of a better term). However, we often use double standards when the results of the cycle are back. When the cycle succeeds, we are happy to take all the credit ( which patients are generous enough to give us as well !)  However, when the cycle fails, we tell the patient – Bad luck – try again ! The outcome of an IVF cycle is a combination of both skill and luck ( both the doctor’s and the patient’s), but doctors are human, and are happy to take credit for the IVF successes ; and equally happy to attribute IVF failures to the patient's bad luck.  Because patients know that the doctor’s expertise plays a key role in an IVF outcome, they spend a lot of time and energy trying to find the best IVF doctor – one who is skillful and experienced. However, no matter how good your doctor is, and how “state of the art” his equipment is, the truth is that skill is not enough to assure success.

Because luck is not a scientific word , it‘s a term which doctors don't like using . After all, if the outcome of an IVF cycle is all a matter of chance, then what value does the doctor add ? I am definitely not suggesting that IVF outcomes are purely random, or that patients   and doctors cannot influence this. Good IVF clinics have a much higher success rate than bad IVF clinics. All I am trying to emphasise that there’s a lot about IVF which we cannot control. The trouble is that patients don’t want to hear the truth. They want certainty . They want a doctor who is omniscient and omnipotent – not one who is brutally honest ! This is why when a cycle fails, rather than acknowledge that it may be just because of bad luck, doctors will run panels of very expensive ( and useless) tests to try to scientifically document why the cycle did not work (inspite of their putting in all their skillful efforts ). Trying to seek wisdom after the event usually does not help and just wastes a lot of time and money.  However, it’s very easy to fool patients; and they are happy with the illusion that their doctor is applying even more of his scientific skill to get to the root of the problem, so he can find a scientific solution and help them to have a baby ! Sadly, even doctors get fooled by randomness. Thus, if they "treat" a patient who has failed 3 IVF cycles with IVIG and she then gets pregnant , they start believing that it was the IVIG which made the difference- and then start giving IVIG to everyone !

Because of the intangible luck factor, there is still  a lot of mystique about IVF. Many patients are very impressed by IVF doctors who do lots of tests ( and send the samples abroad to get reliable results, because the facilities for these tests are not available locally !) ; who monitor them very carefully on a daily basis ( in a biological system, results do not change daily, and these tests just add to their stress levels and their bills) ; and who “treat” them with expensive IV infusions ( of unproven value). Science can be seductive – especially when it is complex and beyond your understanding ! Patients are very comforted by all this activity. Little do they realize that a lot of these are just unproven rituals , which are just cloaked with a scientific garb. However, they do seem to serve a useful psychological purpose, in that patients are convinced that the doctor is very detail oriented, and has not left any stone unturned in helping them to get a baby.  Whether these rituals actually help to improve success rates or not is unproven – which is why while the IVF clinic which uses them will swear about their efficacy and attribute their high success rates to these interventions , so that patients start believing that this is the unique “magic sauce” which only they provide , other IVF doctors understand that most of this is just expensive wasteful hocus-pocus.

While medical skill is something we can measure and check , how do you control luck ? This does not mean that patients just blindly go to the nearest IVF clinic and leave everything upto chance. It is possible to create your own luck by being well informed, so that you can ask intelligent questions, and make sure your doctor is skillful and has the expertise and equipment needed to provide high quality care. As a patient , you do need to acquire the skills needed to become an expert patient, so you have peace of mind you did your best to maximize your chances of getting lucky !

What to improve your luck ? Want to check your doctor has the skills needed to maximise your chances of IVF success ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !




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