How to bounce back after a failed IVF cycle

 

After an IVF cycle fails , the commonest question patients ask is – Why ?

This seems to be a simple, straight-forward question , given the fact that IVF failure is so common, but the answer can be surprisingly complex . This is because there are so many possible factors which affect embryo implantation , and it can be very hard for doctors to pin point what the exact causes are for an individual couple.

Unfortunately , rather than admit the truth to patients – that medical science doesn’t have all the answers - doctors often subject them to a whole battery of additional tests . Then, to add insult to injury, since some of these tests are bound to come back as abnormal ( even if they aren’t of any clinical importance), they propose additional invasive and expensive treatments , such as PGD, immune therapy, and ERA testing , and suggest to patients that this additional information will improve the chance of success in the next IVF cycle .

This is completely false , because more information does not increase pregnancy rates , simply because so much of this information is irrelevant, and just causes doctors to go down many rabbit holes, chasing expensive red herrings !

This is why it’s helpful to use a simple framework , so that you know what to do for your next cycle when the first one fails.

Start by simplifying, and breaking down the causes of IVF failure into two groups . One is stuff which you can do something about , and the other is all the rest, which you can't do anything about . For example, you can’t become younger, so if you are older , your ovarian reserve is likely to be poor , and you are likely to be a poor ovarian responder, no matter what protocol the doctor tries. It becomes very difficult for a doctor to fix this underlying problem,  because ovarian reserve is a biological fact of life, and the drop is irreversible.

The good news is that often the cause of IVF failure is something that can be fixed ! The commonest cause of IVF failure in Indian IVF clinics is a poor IVF lab – one that is poorly equipped, or that doesn’t have a full-time experienced expert embryologist.

The good news is that it’s easy to identify these bad IVF clinics – they hide information from patients by refusing to share photos of their embryos with them.  If your clinic doesn’t do this, it’s easy to identify that they are incompetent, and you need to find a better clinic – one that is open and transparent , respects their patients, does only blastocyst transfers, and provides embryo photos routinely to all their patients.

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Read more at https://blog.drmalpani.com/2021/03/how-to-check-on-your-ivf-doctor-so-you.html

When sexual difficulties cause infertility - and how you can treat them at home

 

One would think that in this day and age , where everyone has free access to the internet, most adults would be very well informed about sexuality as well as fertility , but unfortunately, the number of myths and misconceptions in this space is mind-boggling.

In fact, the internet has exacerbated the problem of misinformation, because a lot of the " sex education " that teenagers get is through watching porn online. This misleads them , and they have a very distorted perception of the truth . An even bigger problem is that they don't even realize how little they know, as a result of which they continue to remain clueless .

Others get snippets of "facts" from friends, or advice from " aunties ", who don't know too much themselves, but think of themselves as being experts just because they have made a baby in their own bedroom.

This is one of the reasons why sexual problems such as premature ejaculation , erectiledysfunction, and vaginismus have become such common causes of childlessness.

These issues are swept under the carpet , partly because patients don’t know how to describe them; partly because they don't volunteer this information because they are ashamed; and partly because doctors don't have enough time or empathy to be able to ask questions about these sensitive issues to be able to get at the truth .

The problem festers, and becomes worse over time, because it is caused by psychological issues, and these become self fulfilling prophecies. The poor couple have absolutely no idea how to get out of this chakravyuh , and because it's such a touchy subject, they don’t have the courage to resolve it, because they don’t know how to find reliable information about this topic.

There are many quacks out there – both online and in the real world – who take these gullible, ignorant and vulnerable couples for a ride.

The good news is that these are extremely easy problems to solve , and you need to have the confidence that you can fix them for yourself in your own bedroom !

A very useful tip to remember is that you need to differentiate between baby-making sex, and having sex for giving each other sexual pleasure . If you try to combine the two , especially when you have sexual difficulties , you will just end up making the problem even worse !

These problems need to be solved one step at a time, and it can take time to solve psychological issues. This is why setting your priorities is so important. If getting pregnant is your primary goal, then you can use mutual masturbation to give each other sexual pleasure, and utilize self-insemination to get pregnantquickly. Don’t try to optimise making love with making babies at the same time – this will just waste precious time, and create more angst and frustration.

 Remember that there is no correlation between sexual pleasure and fertility – after all, even a woman who gets raped can get pregnant ! Making babies is  a simple biological process , and you shouldn't confuse orgasm, sex, and fertility !

The effect of the Roe ve Wade judgment, Reproductive Tourism and Indian IVF clinics

 

The US Supreme Court's decision to reverse the landmark Roe vs. Wade decision, which allowed women the right to legal abortion, has created a major crisis of confidence amongst educated American women . They are being deprived of their right to make their own choices once they get pregnant !

The problem is that the US is becoming an increasingly polarised society, and while the pro-choice vs. pro-life battle has always been a contentious issue , it is becoming increasingly clear that a society that today decides to curtail the rights of pregnant women may tomorrow decide to infringe on the rights of infertile women as well, and they may no longer be free to decide what they want to do with their frozen eggs and embryos . Thus, the US Govt may rule that frozen embryos are potential unborn babies, and cannot be discarded, and will need to be transferred into the woman’s uterus, whether or not she wants to get pregnant !

Sadly, activists, bureaucrats and judges don't seem to understand the difference between an embryo in the IVF lab and a fetus in the uterus !

The US Govt seems to take pride in telling women what to do , rather than giving them the freedom to make their own choices . A natural consequence of this will be a boost to reproductive tourism , and many American women who want to pursue IVF and make their own decisions as to what to do with their own frozen embryos will choose to do IVF outside the US.

India is going to be an extremely popular destination because the Indian IVF law respects the right of patients to do what they feel is right for themselves , and not force them to do what the Govt demands, depending on who happens to be in the majority in the US Supreme Court.

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

My IVF cycle failed. What do I do next?

Failing an IVF cycle can be heartbreaking. It's often your worst nightmare coming true. You've gathered all that money, taken that big risk, taken all those shots, and done everything possible in order to get pregnant, and blindly followed all the advice given. No, you have not complained even once. And the doctor was so hopeful and optimistic and yet the cycle failed and you feel you've let everyone down - that your body doesn't work properly. That the embryo didn't implant, that you must be cursed, that your fate is bad. And that if that cycle fail, you're never going to get pregnant. After if IVF fails, then what else is left for the future? 

You you need to remember that the pregnancy rate is never going to be a hundred percent ,  and that in fact, the odds of failing in a single IVF cycle are actually much more than the odds of succeeding in a single IVF cycle. But over time -  over multiple cycles, the odds are then stacked in your favor. The important thing is to analyze the failed cycle, so you can learn from it. so you can learn what to do differently the next time. 

Now this might seem quite daunting for a patient. What do I understand about IVF? I'm not a doctor. I do everything my doctor tells me to do. My doctor was very hopeful and he was sure I was going to  get pregnant. And yet it failed. Is there any hope for me at all? 

Part of the problem is sometimes patients aren't even sure that they can trust the doctor , because after the cycle fails, the doctor comes up with all kinds of spurious reasons and explanations for, "Oh, maybe the embryo wasn't good". "Maybe your uterus wasn't good. "Maybe your uterus rejected the embryo". "Maybe you have some immune antibodies". "Maybe we need to do some additional tests" - all kinds of excuses . And you wonder why didn't the doctor tell you all this before doing the embryo transfer rather than after the cycle fail. So your confidence levels, not only in yourself, but in the doctor also, are going to go down. 

You need to understand that IVF isn't really as complicated as most doctors make it out to be after all, what are the four things which you can change in an IVF cycle. That's all you need to figure out. 

There are eggs. There are sperms. There is the uterus.  And finally there is the doctor. So these are the only four levers, which you can change. Now, if you have a top quality blastocyst ( and the doctor has given you a photograph of this), the transfer was smooth, and your endometrium was good, then the reality is there's no need to change anything. It's just a question of repeating the cycle until it works. And of course, if you have a frozen embryo then repeating it is much easier because the cost is much less and you don't need to take injections. You need to come to the clinic just 2 or 3 times and the doctor puts your embryos  back and you have an extremely good chance of getting pregnant -  maybe in the second or the third cycle,  provided you don't give up and get disheartened. 

But suppose the cycle didn't go well, then what do you need to analyze ?  Did you get poor quality embryos? Because your eggs weren't very good ? Was this because your your ovarian response wasn't good because you have poor ovarian reserve ? Or did the eggs not fertilize well ? Or did the embryos started fragmenting from day two or day three.

Or was it a problem with the sperm? Did you have total failure of fertilization? If you did ICSI (Intra Cytoplasmic Sperm Injection). maybe not enough of the eggs fertilized properly perhaps because the embryologist just didn't do a very good job. 

Analysing uterine receptivity is not very hard, because if you can see a tri-laminar thick endometrium on an ultrasound scan, this usually means the uterus is receptive. 

Of course, when a cycle fails, doctors want to change something, and patients want them to change something too . And the easiest thing to change is the uterus because the commonest reason a doctor gives is - Your uterus rejected the embryo, which is why it didn't implant.

Even though this is a lie, this is something which patients are very likely to believe. This is partly  because they have low self-esteem as a result of their infertility, and they know their body doesn't work properly. And then when, in spite of the fact that the doctor made an embryo, put it back, and yet they didn't get pregnant , this means obviously their uterus is flawed ! It rejected the embryo and they need to change the uterus and do surrogacy. But the reality is that most IVF cycles which fail aren't because of problems with the uterus because the uterus is usually passive. The problem is often with the eggs, rather than the uterus.  

And finally, the fourth variable is the doctor. If you feel the quality of care, wasn't good; the doctor didn't spend enough time with you; the doctor didn't bother to answer your questions.; was was not open, and didn't give you photos of your embryos ; or you never got a chance to see the doctor because he was busy in some other clinic and you had to talk to assistants every time. This means it's time for you to consider changing your doctor. And if you're not sure what to do, please reach out to us.

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

What to do if you are stuck with a bad IVF doctor

 

Most patients are very naïve when selecting an IVF clinic, because they believe that all IVF clinics are equally good. They will sign up for IVF treatment at the nearest clinic , or at a clinic to which they have been referred by their family doctor , or perhaps to a clinic they have read about in an ad .

However, after they start their treatment , they realise that they are receiving very poor quality care . After they have paid their fees, they don’t get to see the brand-name doctor, and their treatment is handled by clueless juniors and disinterested assistants.

They have no idea as to how their cycle is progressing , and the clinic refuses to share basic medical information ( such as the number of follicles on the ultrasound scan, and their sizes). They refuse to provide photographs of the transferred embryos , so when the cycle fails, the poor patient has no idea what the real reason for the failure is .

The doctor then starts Operation Coverup ! He hides all the information, and then pushes the patient into doing even more tests, or suggesting more expensive treatment , by blaming the patient’s eggs, sperm, or uterus for the failure , when in fact the real reason for the failure was the fact that the doctor was incompetent , which is why the embryos were of poor quality.

Patients are smart , and they suspect the doctor is hiding information from them , and not being honest, but they don't know what to do when they are stuck with a bad doctor. This is partly because they have already spent so much money , that they are very reluctant to walk away – especially when the clinic has signed them up for a 3-cycle package by offering them a discount for this !

They are scared to take the time and trouble to find a new doctor , because they can't really be certain that the new doctor will be any better than the old one , and they are scared they will end up jumping from the frying pan into the fire. Another fear is that the new doctor will make them repeat all the tests all over again , meaning they will end up wasting even more time and money.

The one thing you should remember is that if you are stuck with a bad doctor , then continuing with him will only lead to more grief , and will just make a bad situation worse. There's no point in regretting what you have done in the past , because this is a sunk cost and you can't undo it, but you can definitely learn from your mistakes , so you can choose a better doctor the next time around !

Your first step is to get a copy of all your medical records , including photos of your embryos. If the clinic refuses to share this , please remember that your medical records are your property , and doctors cannot refuse to give them to you ! If they do, send them a legal notice please !

After you have obtained your records, the next step is to get a second opinion , so that you can determine the lacunae in your treatment ,  and can move on to a better clinic . The good news is that your ability to find a better clinic will now increase dramatically because of all the mistakes which you made in your first IVF cycle ! 

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

What to do when the doctor isn't able to collect any eggs

 

One of the reasons IVF cycles fail is because doctors tell patients that they weren’t able to collect any eggs during the egg retrieval . This can come as a rude shock, because patients expect doctors to be able to collect one egg from each follicle , and it’s very hard to understand why they weren’t able to retrieve any eggs at all .

When doctors don’t get any eggs, they commonly lie to the patient, and tell them they suffer from the rare condition called empty follicle syndrome ! This is not true, because empty follicle syndrome is a very specific condition which can be diagnosed only by doing special tests, but doctors don’t bother to do this , and will use this diagnostic label as a pretext to cover up their own incompetence, which is what really caused them to fail to collect any eggs.

Let’s look at the real reasons why some doctors aren’t able to find any eggs at the time of egg retrieval. One of the commonest reasons is that the follicles have already ruptured before the start of the egg collection . This is not uncommon, especially in large clinics that do many egg collections in a day , because they "batch" their patients together into one group. If the doctor waits for longer than 38 hours after the HCG trigger , the follicles will rupture, and the eggs will be lost in the peritoneal fluid. However, the doctor will refuse to take any responsibility for this negligence, and will hide the truth so that patients remain completely in the dark.

Another reason why the doctor may not be able to collect any eggs is that the doctor may not be technically competent . This is becoming increasingly common in IVF corporate clinics that run large chains , because they are happy to hire any doctor they can find , no matter how inexperienced or clumsy he may be. This is because their focus is not on providing a high quality clinic service , but on doing as many IVF cycles as possible , to maximise their profits. Many of these junior doctors don't have the experience or the expertise to collect eggs for challenging patients—especially when there are only a few follicles ( in patients with poor ovarian reserve), or when the ovary is hard to reach because of adhesions. The doctor blames the poor ovarian function, and then uses this as an excuse to tell the patient to use donor eggs for the next cycle.

Another problem could be a bad embryologist , so if he is not experienced enough , he may fail to identify the oocyte cumulus complexes in the follicular fluid that the doctor sends at the time of egg retrieval. He will claim that no eggs were found, and the hapless patient will never get to know the truth , because it's concealed , and no one is willing to take responsibility for the mess.

Finally , another reason could be equipment malfunction , so if the lab is not well equipped , or if there is a loss of electrical power, the suction pump used for the egg collection will not create the negative pressure needed, or the stereozoom microscope used in the IVF lab will stop working.

The result of this sad saga is that the poor patient will waste all their time , money, and energy - and to add insult to injury, the doctor will lie and tell the patient that there was a problem with her eggs, and she will need to use donor eggs in her next treatment cycle, which is a complete lie.

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

Embryo transfer versus embryo implantation

 

One of the problems that plagues IVF today is that most IVF patients are still very poorly informed about the medical details of an IVF treatment cycle . Patients justify their ignorance by saying that they don’t need to worry about the technical minutiae , because that is the job of the doctor ; they don’t understand the medical jargon, and that a little knowledge can be dangerous !

If you do go to a good doctor who takes the time and trouble to explain the details to you, and is transparent and accountable , you will be fine . But what happens if you don't go to a good doctor ? Or if your doctor is not willing to be open and transparent about your treatment, and who hides critical medical  information from you, because they know they are incompetent ? This is the kind of doctor who will take you for a ride , because you don't know enough to be able to protect yourself – and sadly, this is still the majority in India today.

This is why it’s so important that you invest in Information Therapy ! A good doctor appreciates patients who have taken the time and trouble to educate and inform themselves,  because they have realistic expectations of IVF treatment, and this makes life much easier for both the patient and the doctor , because they are on the same page .

The patient knows exactly what to expect, and can check if the doctor is doing this, because they understand what to expect. This also reduces their stress levels because they are less anxious, since they know what’s going to happen next.

On the other hand, bad doctors get very upset when a patient is well informed because they know they are not going to be able to cheat this patient . They often get angry with the patient who asks them questions, and will insult them by telling them that there is no point in their becoming a half-doctor !

You need to protect yourself , because you can't automatically assume that every doctor you go to is a good doctor . This is why you need to understand the difference between embryo transfer and embryo implantation . Embryo transfer is a simple clinical procedure that we do routinely. This is done under ultrasound guidance, and good clinics will always provide photographs of embryos , so that patients know that the treatment has been done well . Until the point of embryo transfer , the medical treatment is in our hands , but after we transfer the embryo into the uterus , whether that embryo will implant and become a baby is not something which anyone can control , because this is a biological process , and human reproduction is not very efficient . This is true , whether you are trying to make babies in your bedroom or whether you are doing IVF  - and this is why every fertile couple doesn’t get pregnant every month they have sex !

We have no control over the implantation process – it’s still a black box for us. This is why patients need to understand the difference between embryo transfer and embryo implantation, and this knowledge is extremely important , because you can then decide what to do next in case the first IVF cycle fails !

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