Saturday, April 04, 2015

Miscarriage after IVF


Patients get very excited when they get pregnant after IVF, but if they miscarry, this is often the last straw that breaks the camel’s back. Many infertile women suffer from low self-esteem and the miscarriage just exacerbates the problem. They feel - not only could I not get pregnant in my bedroom , I couldn't even hold on to my pregnancy after the IVF cycle.

Many of them feel guilty that the miscarriage was a result of something they did - or didn't do ! Did I lift a heavy bucket and put too much pressure on the uterus as a result of which my baby was expelled ? or was it because the scooter I was driving went through a pot hole and the jerk caused the baby to fall out ? was it because I missed a dose of Susten ? or because I didn't rest enough ? or because I had an argument with my boss ? The mind plays all kinds of games, and some of them feel that they killed their baby , or that their uterus is flawed and damaged. The victim blaming tales their friends and older relatives tell them about the causes for a miscarriage just make a bad situation worse.

This is why a lot of patients who miscarry after IVF think surrogacy is the right treatment for them. Actually, their reasoning is completely flawed and this is the reason why.

The very fact that your embryos implanted in your endometrium and you got pregnant means that your uterus is fine -  if your uterus was truly damaged, it would never have allowed implantation to occur. The truth is that the commonest reason for a miscarriage is a problem in the embryo rather than the uterus - the seed is the active component, and is much more important than the soil , which is passive in comparison. This is why we tell patients that if you have a miscarriage after an IVF , it's much more likely to be an egg problem rather than a uterine problem.

Now I agree this is not very intuitive . Many patients feel that if there is an egg problem , then doing the IVF has helped to fix that. You may believe that the very fact that you got an embryo to transfer means that the egg is now no longer an issue . Doesn't the fact that the embryos are Grade A mean that the eggs have no further role to play in the implantation process ? Once the doctor transfers Grade A embryos back into your uterus , and it then fails to implant , it's " obvious " that it's the uterus which is flawed.

The best analogy I can give them , in order to correct their flawed thinking, is to think of a car which is going from Bombay to Pune, and where the fuel tank is only half-filled with gas . Because you don't have a fuel gauge, you cannot check how much fuel is left in the tank. This means that when you reach Khandala, the halfway point, the car will stop because you've run out of fuel. When a car which has been running fine until that point stops all of a sudden, you start wondering if there's a problem with the engine.  Because there's no way of testing the fuel level, you start checking the battery and the carburetor.  You are quite likely to assume that because the car ran smoothly until now, there must be enough fuel to take you all the way to Pune.

This is exactly the same situation with both the mitochondrial energy stores of the egg
( which drive embryo cleavage) and the genetic competence of the embryo ( which allows it to grow and develop into a healthy baby).  These eggs may have enough energy to allow the embryo to develop upto a particular stage, but it arrests after this because it runs out of energy.  Similarly, the embryos may have enough genetic competence to develop into a fetus, but they then don't have the ability to grow any further , ending in a miscarriage . Sadly, we still cannot test either the mitochondrial energy stores of older eggs ( these eggs look completely normal), or the genetic makeup of the embryos ( CCS only allows us to check the number of chromosomes, which is a fairly crude test).

We need to remember that a miscarriage often represents nature's defence mechanism , so that rather than give birth to an abnormal baby , it terminates the pregnancy once the lethal error has been recognised.  Patients need to remember that the pregnancy rate in patients with repeated failed IVF cycles ( repeated implantation failure) or recurrent first trimester miscarriages is much higher if they opt for donor egg IVF, rather than surrogacy . After all, if your uterus is normal, and the problem is with your embryos, then how will transferring these embryos into another woman's uterus improve your chances of having a baby ?


Not sure what to do after an IVF miscarriage ? 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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