When we review the treatment protocols of patients who've done IVF in other clinics, it amazes me to see how regimented and straight-jacketed their treatment is. This is especially the case with patients who have undergone treatment in the U.S. When they are being superovulated with HMG injections, they are often ordered to take their injections at a specific time every day. They have to follow a long list of instructions and it’s obvious that they are being kept on their toes. In my opinion, this regimentation does nothing in terms of making a difference to the final outcome. For example, they are told to take 2 amp Follistim ( FSH) at 8 am sharp and then 2 amp Menopur ( HMG) at 4 pm sharp. Not only is this a strain on the poor patient (who now has to take 2 separate shots, it ends up playing havoc with their daily schedule and disrupts their life). In reality, this kind of rigorous scheduling has no biological basis at all. Let me explain:
• When the HMG/FSH is given subcutaneously, first it gets deposited in the subcutaneous fat
• From here, it then gets slowly absorbed and enters the bloodstream
• It then acts on the ovaries to stimulate follicular growth
Given the pharmacokinetics of these drugs, flexibility in administering the shots couldn’t affect their biological activity. But when you instruct patients to take their shots only at specific times, they are always worried that if they miss the “perfect” time, it will affect the outcome. They end up fretting and fuming about something that is inconsequential from the clinical viewpoint.
Just adding to Stress Levels
And so, if they are driving home and get stuck in a traffic jam and end up taking their injection 2 hours later than the scheduled time, they worry themselves silly that this delay will have ruined their chances. What’s even worse is that they also end up concealing this information from their doctor, as they are worried that the doctor will admonish them for being careless.
This adds to their stress levels and they are worried that their IVF cycle results will also get messed-up. This is especially true when their cycle doesn’t go as planned and the patients end up blaming themselves. They conclude that their eggs didn’t grow properly because they didn’t follow their doctor’s orders to the tee. What’s even worse is that they can’t distinguish between what’s essential and what’s just chaff.
The truth is that these minor variations are unimportant in a biological system. It’s just something that certain doctors do to impress the patient about how fastidious their clinic is. I just feel that doctors have to learn to be kind to their patients. Ironically, some patients are more than happy to unfailingly follow a regimented schedule. Their perception is that a clinic which is so particular about specifying timings is undoubtedly very detail-oriented and that it will have a very high success rate.
I’d like to be very blunt at this point and say that this is all 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 variation of a few hours in schedule won’t make the slightest difference.
“Real World” Research Matters
Thus, while the timing of the hCG trigger is extremely critical (because there is no window of opportunity to mess up), fortunately this isn’t so important with reference to the daily HMG shots. It’s important that patients learn which instructions are critically important and the ones that can simply keep in view, but not obsess or worry about. Doctors need to learn to become kinder, so they can reduce their patient's stress levels, but it's very unlikely that they are going to bother.
It's patients who need to take control and this is the kind of practical "real-world" research study that 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! Doctors and pharmaceutical companies are not going to bother to do this - but the outcome of such a study would be extremely useful to patients.
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