Saturday, April 03, 2010

How good is your IVF doctor ?

8 cell stage, prior to morula formationImage via Wikipedia

How can a patient judge how good ( or bad) an IVF clinic is ? Success rates are a useful marker, but they have their own limitations , because they apply to groups of patients, not to individuals ! Also, clever clinics can easily game the system to artificially inflate their success rates.

What do you do if your cycle fails ? Should you continue with the same doctor ? Or should you find another doctor ? The outcome of an IVF cycle is always uncertain, and just because the cycle fails does not mean the IVF doctor is incompetent ! It's often much easier to stick with the same clinic. Some of this is just inertia - after all, he "knows your case" and you now have a relationship with him, so why switch ? Also, finding another doctor is hard work , and is it worth taking all that effort to do so if your present doctor is good enough ?

The secret fear is that it's possible that the reason for the failure is the fact that the IVF clinic you have selected is not very good, and you'd actually be better off going to a new doctor ! How do you make this decision ?

In order to do so, let's look at the three tangible deliverables a good IVF clinic can provide.

1. Growing eggs
2. Making embryos
3. Transferring the embryos

1 . Growing eggs. This is called superovulation and is the basic clinical skill of the IVF specialist. The doctor needs to select and adjust the dose of HMG used for superovulation , and to monitor the cycle to ensure optimal growth of eggs. While it's easy to get most young patients to grow lots of eggs, this can be quite a challenge for older women ; and for those with poor ovarian reserve. While most clinics will use a rigid standard superovulation protocol, a good clinic will tailor this to the patient, depending upon her age; antral follicle count; ovarian reserve; and her response to superovulation in prior IVF cycles. A good clinic will show you your follicles during the ultrasound scanning, so you can understand what is happening !

Patients with PCOD are also quite taxing, because of the risk of developing OHSS. They need careful gentle superovulation, with close monitoring.

Egg retrieval is another important skill. While many IVF doctors take pride in being able to complete an egg collection in 5 minutes, this is not necessarily in the patient's best interests. This is especially true when there are only a few follicles. In these patients, the technical skill of the surgeon can make all the difference between retrieving 6 eggs or just 2 eggs. Careful, patient surgeons will spend time carefully flushing each follicle, to maximise the chances of collecting all the eggs you have !

2. Making embryos. This is the heart of IVF technology and this is what the embryologist does in the IVF lab. For many patients, this remains a "black hole" area , but it is the expertise of the IVF lab which marks the key difference between a mediocre clinic and a good clinic. Lab skills play a key role in the ability of the clinic to make a large number of good quality embryos. Not only does this maximise chances of success, it also allows the clinic to freeze spare embryos. Does the clinic offer blastocyst transfer ? freezing using vitrification ? How many incubators do they have ? These may be technical minutiae, but make a world of a difference in the final outcome ! A good clinic will document the quality of your embryos by providing you with photographs !

3. Embryo transfer. The final step in the process is that of embryo transfer. This is a blind process, which is deceptively easy to do, but needs to be performed with love, skill and care ! The endometrium should be optimally receptive; and there should be no bleeding or trauma during the procedure. If there is cervical stenosis, a good clinic should be able to offer the option of tubal transfer using the ZIFT technique.

If your clinic refuses to treat you like an intelligent adult and share information with you; if they refuse to provide you with a treatment summary; if they do not show you your follicles during ultrasound scanning; and if they do not give you photos of your embryos, you should beware ! These are all red flags, which suggest you might be better off finding a better clinic !

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