Sunday, July 12, 2009

Between a rock and a hard place - IVF patients with complex problems

Most difficult IVF patients ( those with a poor prognosis) usually have just one problem – either poor eggs or a poor endometrium. However some really unfortunate ones have a double whammy - they have both poor eggs as well as a poor endometrium. This often means that both doctor and patient are caught in a bind.

If there had been a lot of eggs and a poor non-receptive endometrium , the simplest option would have been to freeze all the embryos ; and then work on improving the endometrium so that the frozen embryos could be transferred in a subsequent cycle after thawing them when the endometrium was ripe.

However if there are only a few eggs , we are likely to get only a few embryos , and often these may be of poor quality so that they may not survive the stress of a freeze and a thaw. Is a bird in the hand worth two in the bush ?

One option is to cancel the cycle and then consider alternative options such as using donor eggs.

Another option is to accept the fact that the chances of implantation are poor because of a poor endometrium , but to go ahead with the transfer anyway in the fresh cycle.

The other option is to proceed with the egg collection ; and then make a decision whether to transfer or not , depending upon the number of embryos obtained and their quality.

These are all difficult decisions which tax both the patient's emotional stamina and the doctor’s clinical judgment. I feel the best approach is to make a list of all the options ; to try to quantify the probability of success with each option, using the doctor’s best guesstimate; and then to allow the patient to make the final decision. Patients should follow the path of least regret , so they have peace of mind they did their best , even when the odds were stacked against them.

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