Monday, March 23, 2015

Day 2 versus Day 5 transfer



We prefer doing Day 5 transfers because it allows us to select the best embryos , and this increases the chances of a pregnancy. Allowing the embryos to grow in vitro to Day 5 allows them to “ compete “ with each other, so we can transfer the best ones to the uterus.

It’s an easy decision to transfer on Day 5 as compared to Day 2 , when there are lots of eggs and lots of embryos . However, what do we do for poor ovarian responders – patients who grow only 3-4 eggs, and we have only 2  embryos on Day 2 ?  There’s little point in growing them further in vitro, because we only have 2 embryos to choose from, so why not go ahead and transfer both on Day 2 ? After all, if we try to grow them to Day 5 and they stop growing ( arrest in vitro), then the patient will have no embryos to
transfer , which means her chances of getting pregnant will be zero. Isn’t a bird in the hand worth two in the bush ?

The decision boils down to a personal preference – should we  take a short-term approach  versus a long-term approach ?

Let’s consider the short term option first, where we transfer the embryos on Day 2. We don’t want to take a risk, and if we transfer, and the patient gets pregnant, she will be happy – and so will the doctor. However, if she doesn’t get pregnant, we’ll never know why the cycle failed. Was it because the embryos arrested on Day 3 ? or 4 ? or because there was an endometrial problem which prevented implantation. By transferring too early, we have lost the golden opportunity  to answer this key question about embryo competence.

If we decide to grow to Day 5, and we get good blastocysts, every one is happy, because we’ve followed text book protocol, and the patient has peace of mind she’s received the best possible treatment.

What happens if the embryos arrest in vitro and there are none to transfer on Day 5 ? The immature patient will be unhappy and angry. She will kick herself – and her doctor – for not transferring the embryos on Day 2 ! She may always feel – perhaps if I had transferred them on Day 2, they would have continued to grow in utero and would have implanted. By leaving them outside, I frittered away my chances of having a baby. She may even blame the doctor for the failure of her embryos to grow !

Transferring on Day 2 is much safer for the doctor as well, because at least he can give both himself and  the patient the pleasure and satisfaction of having had a transfer. Sadly, this pleasure can often be only transient – and when the cycle fails, the patient is back to square one. However, for many IVF doctors, the end point of an IVF cycle is the embryo transfer, and if they achieve this, they can proudly tell the patient – we did everything humanly possible – the rest is in God’s hands. This way, even if the cycle fails, at least the patient doesn’t blame the doctor. She blames her fate, and happily comes back for a second cycle, because she doesn’t realize she has received poor medical care.

The problem is that being willing to wait to grow the embryos to Day 5 requires a very competent doctor, who knows his IVF lab is excellent, and who is confident that if the embryos will cleave in utero, they will do so in vitro in the lab as well; and one who knows that if the embryos are going to arrest in vitro, they would have arrested in the uterus as well. This requires a very mature patient as well, who is willing to put up with the short term pain of not having a transfer, because she has now learned valuable information about the competence of her embryos , because they arrested in vitro and failed to form blastocysts. This way she knows that the problem is her egg quality, and she can then start considering alternative options  for her next cycle more intelligently based on this knowledge ( such as using donor eggs).

Patients need to be wise enough to understand that the endpoint of an IVF is not always only a baby . An IVF cycle provides invaluable diagnostic information , which can help us to formulate a treatment plan for the next cycle, to maximize the chances of success. These patients can make a much better, well-informed mature decision , if they are will willing to accept the risk of the short-term pain . This kind of patient will not blame the doctor because her embryos arrested.

However, this approach requires a lot of patience and maturity , from both the doctor and the patient. Patients can become quite agitated if the embryos arrest, and this is why patient counseling is so important.. Doctors need to be open and transparent, and give patients photos of their eggs, and arrested embryos, so they can see exactly what happened in the IVF lab. This way , the doctor does not need to get defensive, and he can honour the patient’s personal preferences.

The trade-off is between short-term pain and long-term gain , and sometimes valuable information from an IVF is lost , because some doctors are focused on just transferring the embryo back into the uterus.
However, this is a just a short-term milestone you have reached – but means you are no closer to your final goal – of having a baby.

However, doctors who are not confident about their lab’s ability to grow embryos to Day 5 will often push patients to transfer them on Day 2.  Then, when the patient does not get pregnant, they can label this “failed implantation”; run a battery of expensive tests, to “diagnose” the problem; and even advise an expensive
( and completely incorrect )  treatment such as surrogacy, to overcome the problem of failed implantation.,

We counsel our patients that it’s best to grow to Day 5. Yes, there is a risk there will be no transfer, but the fact that the embryos arrested in vitro provides useful information, which we can use for the next treatment cycle, to maximize the chances of success. If the embryo does arrest in vitro, this makes it easier for the patient to come to terms with the fact that she has a problem with her egg quality ; and this can help her to consider using donor eggs for her next cycle.

On the other hand, if she transfers on Day 2, she’s never sure whether the problem was with her eggs, or with her uterus ! This is why it’s so important that you find a good IVF clinic, which has a robust IVF lab, and routinely grows embryos to Day 5 .

Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

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