Monday, October 06, 2014

Empiric therapy in IVF



Lots of patients who have failed an IVF cycle ( either in our clinic or elsewhere) want us to try something new and different for their next cycle. Common requests are - Can you please prescribe steroids for me ? IV immunoglobulins ? Intralipids ?

They spend a lot of time online, trying to research their treatment options . Maybe there’s something which we didn’t do in the first cycle which can help the second cycle to succeed ? Patients who have failed an IVF cycle can become quite desperate and are happy to clutch at straws. When they read about “the new and latest “ treatment advance, they want us to try this out for them.

The trouble is that a lot of these treatments are empirical. Empirical therapy is one which is based on experience. They have never been proven to be effective in controlled clinical trials . These are supported by lots of anecdotal case reports of success, where some patients have benefited as a result of trying that particular treatment intervention . Now just because there is no clinical trial does not mean that these treatments are not useful – it just means that a clinical trial may never have been done. On the other hand, just because there was a pregnancy after the treatment does not mean that the pregnancy was a result of the treatment . This is a natural bias and this logical fallacy is called the “post hoc, ergo propter hoc” fallacy. Sadly, it’s very easy for patients to fall prey to this, which is why there are so many accounts online of patients who swear that taking IVIg therapy helped them to get pregnant. These are very emotional stories, and it’s easy to conclude that if a patient who has failed her first IVF cycle gets pregnant in her second cycle after taking intravenous immunoglobulin , that it was the intravenous immunoglobulin which caused the second cycle to succeed . However, this is false. If this were true, then doctors would routinely start using IV immunoglobulins for all their IVF cycles – why would they wait for the cycle to fail before using a therapeutic intervention which has been proven to improve pregnancy rates ?

While I have nothing against empiric interventions , I think patients also need to acknowledge the limitations of these . Not only can they be extremely costly , they also have hazardous side effects . For example, the overuse of steroids can cause hip necrosis , and actually harm the patient .

Unfortunately, there is a lot of pressure to treat - not only for patients, but for doctors as well. Doctors have a natural bias to want to something different – even though it’s not been proven to be better. Patients are easily influenced by the success stories they read online – even if these accounts are not scientifically valid . Thus , if 100 patients have taken intravenous immunoglobulin , the ones who get pregnant after taking it will wax eloquent about how effective the treatment is – while the ones who don’t get pregnant will keep silent – or will go one to trying something different. This is why the documentation about the failures of empiric therapy is so poor. The major risk is the false hope they create in patient’s minds and hearts.

I'm perfectly okay with using empirical therapy, provided patients understand that it is unproven ; and if it is inexpensive and safe . Thus, I think it’s fine to use interventions such as acupuncture , DHEA , vitamin D and other supplements - but for a lot of the other stuff ( such as IV Ig) which is expensive, risky and unproven, I would say no, unless the patient twists my arm. As a scientist, I am forced to depend upon reliable scientific evidence, but patients are not bound to follow scientific principles, and are free to do as they please. I am happy to honour patient preferences, provided they do no harm.

Failed an IVF cycle and not sure what to do next ? 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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