Do not allow your IVF doctor to do a Day 3 or Day 2 transfer for you

Many IVF clinics advise their patients to transfer Day 3 ( and even Day 2) embryos back into the uterus . This is especially when they don't have too many embryos , or the embryo quality isn't good , but other terrible reasons are the fact that the “specialist IVF doctor from Mumbai” as to go back in 2 days, and can’t wait to do a Day 5 transfer for you !

The justification ( excuse would be a better word) is that it's better to put the embryo back into the uterus , which provides a “more natural environment” , so it can continue to grow , rather than to keep it in the lab incubator.

Actually, this is a confession of the fact that they know that their IVF lab culture conditions aren’t good , and they don't have enough confidence in their embryologist’s  skills to be able to culture all embryos routinely to blastocysts.

This is why they persuade patients into taking a shortcut and bung the embryos back into the uterus . This way, if the cycle fails, they can blame “ embryo implantation “, rather than take responsibility for the fact that their lab is not good enough to create blastocysts routinely.

 If the lab can’t create good quality blastocysts, the reality is they most probably can’t create good Day 3 embryos either, and their implantation rate is likely to be poor.

However, by transferring them early on Day 3, they can shift the blame for the failure onto the patient , and cover up their incompetence.

 Remember that the right place for a day 3 embryo is not the uterus ! In real life , a day 3 embryo belongs in the fallopian tube which is where it spends about 3- 4 days , before being transported into the uterus . This means, for fertile couples, the embryo has become a day 5 blastocyst before entering the uterus . The right place for a day 3 embryo is either a good IVF lottery , which can create optimized  culture conditions for it to become a blastocyst, or  the fallopian tube – it is definitely not the uterus !

 Please don't allow doctors to take shortcuts by transferring Day 3 embryos , because this reduces your chances of success. And when the cycle fails, they will blame you for the failure, rather than accept responsibility that they didn't do a very good job , because they didn't have the required expertise or experience to grow your embryos to Day 5

 

The problem with travelling embryologists and why this compromises IVF care

The outcome of IVF treatment depends on close coordination between the clinical and the IVF embryologist . This is why it's so important that every good IVF clinic has a full-time embryologist , whose responsibility is to make sure that the eggs the doctor gives them are handled with care , so that they become top quality embryos .

Sadly, there is still a shortage of embryologists in this country , most of whom don't have either the experience or the expertise to provide top quality care for your embryos.

The poor IVF patient gets short-changes, but sadly most patients don't even know this , because there is very little openness and transparency in what is happening in the IVF lab, especially with regards to the qualifications and expertise of the embryologist .

This is why many IVF clinics - specially the new ones - still depend on travelling embryologists to be able to offer IVF treatment.

Now while some of these embryologists have a lot of expertise , the problem is they are always rushing and in a hurry. They are so busy travelling from one city to another , they can only spend 1 or 2 days in one IVF clinic. Now this is great for them , because they can make much more money , but this is not great for the patient . For one thing, the risk of errors happening increases when you treat too many patients at one time by squeezing them all together in 1-2 days. When 5 egg collections are being done in one day, there is a real risk that eggs, sperm and embryos will get mixed up – and the poor patient will never know the truth until it’s too late.

Also, when there are so many patients to treat and so many eggs to fertilise, the embryologist is not able to spend enough time on each patient to be able to do full justice to them. Thus, these clinics are often not able to freeze embryos, because the senior embryologist has gone off to another city, and the junior embryologist left behind is not able to freeze embryos well, as a result of which many of these frozen embryos will die when thawed.

This is why patients continue to get suboptimal quality medical care in most IVF clinics .

It’s high time the government regulated this , and insisted that every IVF clinic should have an experienced IVF specialist as well as a full-time experienced IVF embryologist .

It’s only when they work together that IVF success rates will be good, because the IVF lab is the heart of IVF treatment

 

The problem with satellite IVF clinics and travelling IVF doctors

 Many IVF clinics have setup branches known as satellite clinics in different cities , in order to take advantage of the fact that they have an established brand name . Of course, the fact that they get this brand name because they spend so much money on advertising , and by giving kickbacks for referrals is something which most patients are blissfully unaware about.

 They need to increase the volume of work they do and maximize the number of IVF cycles they perform, because they need a return on investment on their advertising budget , and they need to increase the amount of money they give as kickback because competition in the IVF field is getting increasingly intense , as local IVF clinics start competing with out of town IVF specialist.

 The attraction of these satellite clinics is this “ brand name “ , famous IVF doctor from a large city like Mumbai is going to travel all the way to your town in order to treat you.

Because the doctor has bought a brand name , a lot of patients get tempted into taking treatment, because it’s so much cheaper than having to travel to Mumbai to take treatment from him.

 The tragedy is they don’t realise they are getting short-change . IVF treatment requires close monitoring and careful attention, so it can be tweaked to optimize your ovarian response. When doctors try to this remotely, it’s can’t be done efficiently and effectively , and these satellite clinics are forced to take shortcuts , because they want to maximize their quantity – not their quality.

These brand name doctors depend on assistants and juniors , who more often than not don't have any idea about what's happening , because they just follow the cook-book protocols laid down by the senior doctor.

 This is why the poor patients who pay an arm and a leg for the privilege of being treated by the famous doctor never actually see him – because he is too busy treating patients in his other satellite clinics . His job is done by a locum or another junior, and patients naturally feel cheated when this happens, but because they have paid all their treatment fees, they are helpless, and can’t do anything about this.

Unless patients become more assertive , and start demanding more personalized and customised care because they are paying so much money for this, this sad state of affairs is going to continue, because IVF doctors know they can get away with it .

Their incentive is to maximize their profits by doing the largest number of cycles , rather than try to help each individual patient get pregnant .

This misalignment of incentives is one of the reasons why IVF care in India leaves so much to be desired.

If you want personalised attention from an expert, experienced IVF specialist, then come to Malpani IVF Clinic . We don't employ any assistants, and Dr Anjali and I take care of you personally ourselves 

 

Why don’t all IVF clinics do only blastocyst transfers routinely for all their IVF patients ?

 It has been well documented that the implantation rate with blastocysts is better than with Day 3 embryos.

This is common sense , because a day 3 embryo needs to become a blastocyst before it can implant , and this is why it’s better to grow it in the IVF lab and wait till it becomes a blastocyst before transferring it in the uterus .

The problem with doing a day 3 embryo is it's impossible to predict which Day 3 embryo is going to become a blastocyst, as a result of which a lot of doctors will transfer many day 3 embryos at one time, to maximize the chances of achieving a pregnancy. The problem is that this strategy increases the risk of having a multiple pregnancy . As a result, the neonatal complication rate is much higher , because of the chances of premature labour increase considerably.

 It’s much better to allow the embryos to compete amongst themselves , by culturing them in vitro to day 5 in the lab , so that the embryologist can select the best quality blastocyst, and then transfer only this single blastocyst, and freeze the rest .

Not only does this increase the success rates in the fresh cycle , it also increases the pregnancy rates for the future , because we can then transfer the frozen blastocysts, one at a time.

 Blastocyst transfer is now completely routine in all good IVF clinics, because the technology is so well-established and proven.

This is why it upsets me that doctors continued to do Day 3 transfers.

They take advantage of the patient’s ignorance, and exploit this.

This is either because the doctor knows their lab is not good enough to be able to grow embryos to Day 5, and they want to take shortcuts, so they can then blame the IVF failure to “failed implantation”, rather than a poor-quality lab !

Please insist on a Day 5 transfer, even if you have only 2-3 eggs. Doctors are worried whether they will be able to culture these eggs to Day 5, and will bulldoze the patient into transferring it earlier , but if the doctor is not confident that the lab that is capable of growing a good embryo into a good blastocyst, then perhaps he shouldn't be doing IVF in the first place .

 This is why you should not allow doctors to take you for a ride . Please ask questions proactively, and demand answers, so you don’t get cheated by unscrupulous doctors.

 

Doctor, my HCG level is 120 mIU/ml. Does this confirm my pregnancy is healthy ?

 

One of  the commonest questions which patients ask me is about their HCG level .

Doctor, my HCG level is 120 mIU/ml. Does this confirm my pregnancy is healthy ?

 Now you cannot determine whether the pregnancy is healthy or not based on a single HCG level. We need to measure at least two HCG levels , 2-3 days apart, to see whether it's doubling well or not . If it’s doubling, this is a good sign , which means the embryonic cells are growing well.

However, even this does not tell us if the pregnancy is viable or not, because the HCG is produced by that part of the embryo which is called the trophectoderm , which becomes the future placenta. The baby , on the other hand, develops from the cells of the inner cell mass, which means even if the HCG levels are doubling well , this doesn't necessarily mean that the baby is developing normally.

 This is why it’s so important to understand the limitations of all this testing, and not to get too excited with the results.

Remember that when we test for the health of an IVF pregnancy, we need to measure both the HCG levels, as well as do an ultrasound scan. These are complementary, and need to be interpreted together.

In an early pregnancy, when the HCG level is less than 1000 mIU/ml, there is no point in doing an ultrasound scan , because the pregnancy is too small to be seen on an ultrasound scan.

Once the HCG crosses 1000 mIU/ml, then the scan provides much more information about the viability of the pregnancy.

 Yes, I know this can be a little complex and intimidating , but if you know when and why we do these tests, you will have a much easier time interpreting these results . It’s never enough to leave everything up to your doctor

 

How IVF clinics create work for themselves by issuing incorrect and misleading semen analysis report

 

Since about 10 to 15% of married couples are infertile, one would think that IVF clinics would be quite busy treating infertile couples. However, the truth is that because there is so much competition , and because IVF treatment is so expensive , these IVF clinics are very busy competing for the same set of patients .

One slimy strategy a notorious chain of corporate IVF clinics has done is to make patients infertile, by issuing a false semen analysis report, which no one can challenge. Here’s how they scam patients.

They report every sperm sample they analyse as having teratozoospermia (abnormal spermmorphology) ! There is no documentation  and no evidence , because they don’t provide a stained slide of the abnormal sperm – it’s just a computerized printout. Their racket is to claim that nearly every man who comes to them has less than 4% normal sperms. This high percentage of abnormal sperm morphology is diagnosed as teratozoospermia . The patient is told this is the reason for their infertility , and they need IVF/ICSI treatment to have a baby.

The truth is that checking for sperm morphology properly is a very complex test , and most lab technicians are not capable of doing it properly .

This is why they report everyone as having teratozoospermia, so they can do IVF/ICSI for every couple who comes to them.

This is why it’s so important for patients to be well informed , so they can protect themselves from these rapacious predatory IVF clinics .

If any lab claims you have teratozoospermia, ,insist that they give you the stained slide, so you can get a second opinion from another lab !

 

IVF patients need to learn to be proactive in their IVF treatment

 

When you do IVF, you don’t need to become an IVF expert , but it does mean that you should know enough about IVF to be able to differentiate between a good IVF doctor and a bad IVF doctor , so you don't allow bad IVF doctors to take you for a ride .

Before you sign up for an IVF cycle, please interview the doctor and ask questions !

You need to do your homework as well, so you can assess whether his answers fit in with global best practices  , or if he is advising treatment which is completely contrary to what evidence based medicine guidelines suggest . This means that he may be taking you for a ride .

It also shows whether or not he is willing to share information with you. Is he patient ? Does he take time to explain ? Is he kind and empathetic ? Or does he get irritated ? Is he in a rush ?

Finally, this gives you a chance to assess the chemistry between you and the doctor .

Not every patient is going to like every doctor , and you need to find someone whom you are comfortable with .

Not all doctors are created equal , and this is specially true for IVF, where any gynecologist can call themselves an IVF specialist, even if they have no special expertise or experience in doing IVF.

You cannot afford to leave everything up to the doctor – no matter how posh his clinic, or how highly he has been recommended !

You need to take an intelligent interest in your treatment,  so that no matter what the final outcome is, you have peace of mind that you received world-class medical care