Monday, November 03, 2014

Total failure of fertilization after IVF


For lots of patients , the IVF lab is a bit like a black box . They often they have no clue as to what happens once the doctor has retrieved their eggs. All they know is that their eggs and their husband’s sperm are handed over to the embryologist in the IVF lab; and he then makes embryos from these. The doctor then transfers these embryos after 2-5 days into their uterus, and if all goes well, they have a baby.

For most patients, things go exactly as expected. However, sometimes there are glitches, and we find that patients have no idea what went wrong or why. Even worse, they are not sure what to do differently the next time, because they have such little information as to what happened in the lab.

Not only are patients very poorly informed , many IVF doctors themselves are quite unaware of what happens in the lab. They are basically gynecologists and because they are clinicians , they have very little experience in running and supervising an IVF lab.  They are inexperienced , and have to rely totally upon their embryologist. When things go wrong, the embryologist often hides the truth from the boos, in order to protect his skin. This means that the staff often end up hiding facts from the patient. Sadly, many Indian embryologists are inexperienced. Lots of IVF labs are run by “visiting embryologists” , who just fly down for 1-2 days to fertilise the eggs in the lab, and they aren’t responsible for quality control or incubator maintenance,

One major nightmare in the IVF lab is that of total fertilization failure . Once the sperm have been processed and added to the eggs, the embryologist puts them into the incubator , and then checks for fertilization after 16 hours. If the sperm and eggs are of good quality, and the lab is working properly, over 60% the eggs will fertilise and become single-cell embryos at this time, with two pronuclei.

However, about 5% of the time, none of the eggs fertilise . This is called TFF or total fertilization failure. This is a major disaster for the patient, because this means that there are now no embryos to transfer.

Under these stressful conditions, the doctor has a limited number of options.

Some will hide the truth from the patient, because they are scared that the patient will get angry. They lie, and transfer the unfertilized eggs into the uterus. The patient will never get pregnant, but is fooled into thinking that the doctor did the treatment properly. IVF doctors can get away with this kind of malpractise, because patients are clueless, and don’t demand documentation ( pictures of their embryos).

Others will be a little more forthright and will tell the patient the truth that there was no fertilisation. However, rather than accept responsibility for this situation, they will often turn around and blame the patient, by attributing the failed fertilization either to poor quality eggs or to bad sperm ! They will then suggest that one way of saving the situation is to transfer someone else’s embryos. They will generously offer to do this at “no extra charge” and the poor patient is so desperate to have a baby, they will meekly agree. The doctor then “borrows” embryos from some other patient, and then transfers these into the uterus ( without getting informed consent from the other patient , who ends up becoming an involuntary embryo donor !)

Often the reason for failed fertilization is a poor quality lab. Thus, if the culture medium has expired; or there is an infection in the lab because of unsterile conditions; or the incubator malfunctions because of a loss of electricity, the eggs will not fertilise. Doctors will not share this information with the patient, who has no clue what went wrong and why. They are made to feel like failures, and some doctors will use medical jargon to take patients for a ride.

However, failed fertilization can occur in a good IVF lab as well. When this happens, the majority of the time, the reason is sperm dysfunction. This  means that even though the sperm count, motility and morphology are normal, the sperm are not able to fertilise the  eggs. Remember that IVF is the ultimate test of sperm function !

For these patients, a very effective solution ( in the next cycle) is ICSI. When we give the sperm a piggy back ride into the egg, we can effectively overcome this sperm dysfunction, and fertilisation is usually guaranteed. ( This is why some IVF labs will routinely do ICSI for all patients, to prevent the disastrous
“ failed fertilization after IVF “scenario.)

While the long-term prognosis for these patients is excellent , the short-term heartbreak of not having embryos to transfer can be tremendous. However, we can counsel these patients that we have now been able to find out the reason for their infertility – though this can be an extremely expensive way of discovering the cause ! Sadly, it’s not possible to predict this event, which comes as a rude shock to the embryologist as well.
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Rarely, the reason for the failed fertilization may be poor quality eggs. This is commoner in older women, and those with poor ovarian reserve, when only a few eggs are collected . In these cases, it can be hard for the doctor to determine whether the problem was with the  eggs, or with the sperm; and therefore it’s difficult to counsel the patient properly as to what can be done differently in the next cycle.

If your doctor tells you that all your eggs have failed to fertilise after IVF, what can you do ?

1.    Find out what’s happening to the eggs of the other patients who are taking treatment along with you. If you think your doctor is hiding facts, remember that there is strength in unity, and patients need to get together, so they can find the truth.
2.    Ask for photos of the unfertilized eggs . This is valuable documentation, and will help a lot when you need a second opinion. If the eggs are dead, dark and necrotic, this suggests that they have been killed by an infection in the lab
3.    Ask the embryologist to check if the sperm are still swimming in the culture medium when the fertilization check was done. If the sperm are all dead, this suggests that the lab conditions are suboptimal.
4.    You can also ask the doctor to do rescue emergency ICSI with your husband’s sperm with the unfertilized eggs . While the pregnancy rate with rescue ICSI is poor, if you do get fertilization, this will conclusively prove that the problem is a sperm dynsfunction, which can be solved with ICSI.

For the next cycle, your best option is to go in for ICSI, to prevent this problem from recurring.

Did your IVF cycle fail ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so I can guide you as to what to do the next time around !

1 comment:

  1. I had zero fertilisation and after rescue icsi ( done more than 24hours later), there are 5 embryos. I had them frozen but unsure of transferring them or restart a new cycle.

    ReplyDelete

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