Saturday, September 13, 2014

Bells and whistles and IVF treatment


When we review the treatment protocols of patients who've done IVF in other clinics , I am often amazed by how regimented and stringent their treatment is.  This seems to be especially true for patients who have taken treatment in IVF clinics in the US . Thus, when they are being superovulated with HMG injections , they are often ordered to take their injections at a specific time every day.

They are given a long list of instructions which they have to follow scrupulously . While this keeps the poor patient on their toes, I don’t think it makes any difference at all to the final outcome. Thus, when patients are given Menopur and Follistim, for example, they are told to take 2 amp Follistim at 8 am sharp and then 2 amp Menopur at 4 pm sharp. Not only is this unkind for the poor patient ( who now needs to take 2 separate shots, it also plays havoc with their daily schedule and disrupts their life). In reality , this kind of rigorous scheduling makes no biological sense.

When the HMG/ FSH is given subcutaneously, it is first deposited in the subcutaneous fat. It then gets absorbed slowly from here and enters the bloodstream , after which is acts on the ovaries to stimulate follicular growth. Given the pharmacokinetics of these drugs, being flexible in the timings of the shots could not affect their biological activity.

However , by ordering patients to take their shots at a specified time , patients are so scared that they will miss the “perfect “ time, that they end up fretting an fuming about something which is of no clinical importance. Thus, if they are stuck in a traffic jam and take their HMG injection 2 hours late, they are  very worried that this delay will have ruined their chances. Even worse, they are reluctant to share this information with the doctor, because they are worried that the doctor will fire them for being so careless. Not only does this add to their stress levels, they are petrified that it’s because they did not follow the instructions to a T, that they will end up messing up their IVF cycle results. This is especially true when the cycle doesn't go well – and patients will often blame themselves, by concluding that it’s because they did not follow orders properly, that their eggs did not grow properly. This needless complexity just adds to their woes - and they cannot understand what's really important and what's just fluff.

The fact of the matter is that in a biological system , these minor variations are unimportant. A lot of it is excess baggage and "show-baazi" to impress the patient about how meticulous the clinic is. I think it’s far more important that clinics learn to be kind to their patients !  Ironically, some patients are extremely happy to rigidly follow a regimented schedule . They feel that any  clinic which is so particular about specifying timing is obviously very detail oriented , and will have a high success rate.

Quite frankly , this is rubbish ! The timing of the HMG injections for superovulation will not affect their biological activity – there is a wide window during which they can be given, and a few hours here or there will not make the slightest difference. Patients need to learn what instructions are critically important – and which ones they don’t need to stress over. Thus, while the timing of the hCG trigger is extremely critical, because there is no window of opportunity to mess up, fortunately for the daily HMG shots, this is not important, so patients should stop obsessing and worrying about it.

This is the kind of practical "real-world" research study which patients can do . They can compare the outcomes of women who rigorously scheduled their injections, versus those who didn't bother, to see if it makes a difference ! Pharmaceutical companies  are not going to bother to do this - but the outcome of such a study would be extremely useful to patients.

Want to make sure you are getting good quality medical care from your IVF clinic ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?







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