Tuesday, February 05, 2013

Your IVF cycle failed. What next ?


Patients are understandably disappointed and disheartened when an IVF cycle fails. Everyone starts an IVF cycle with the hope that it's going to be their first and their last – that they’ll get lucky and that it'll work for them. When it doesn't , they are now back to square one and have to decide what to do next. So they turn to their doctor and ask - Doctor , what do we do next ? What went wrong ? What can we change the next time ?

This is a difficult question for the doctor to answer because in all honesty there are major limitations in our ability to predict the outcome of any IVF cycle. While we can generalize and provide the clinic’s success figures , remember that these apply to groups of patients – they do not apply to individuals . There is no IVF doctor in the world who can  predict whether a particular cycle will actually end in a pregnancy or not, no matter how well it goes. All IVF doctors will acknowledge that we've been wrong multiple times. There are many cycles which are terrible with poor quality embryos or difficult transfers because of bleeding , and much to our pleasant surprise , these patients get pregnant . Conversely , there are patients who have beautiful text book cycles, with excellent embryos and easy transfers, who don't get pregnant, no matter what we do.

This is frustrating for the patient - and even more so for the doctor . It’s no fun for a doctor to tell the patient,”  I'm sorry I don't know why the cycle didn't work “. This is actually the only truthful answer which the doctor can provide , but this is not what patients want to hear . They treat the doctor as an expert , and want some kind of certainty from the doctor . They naively believe that if we can find out why the cycle failed, what will be able to rectify this the next time around .

The truth of the matter is that just as we don’t know why certain embryos fail to implant in an unsuccessful cycle, we don't know why particular embryos implant in a successful cycle ! We are equally clueless in both cases ! Unfortunately no patient ever asks us - Why did my IVF cycle succeed ! It’s only when we are asked *Why did the cycle fail”, that doctors have to be creative and make up answers. Many will run a battery of tests which are expensive and exotic, and which rarely provide much useful information . This is hardly surprising – after all, how is it possible to track the fate of a microscopic ball of cells , when we put them back into the uterus ?  We all know that human reproduction is notoriously inefficient , and this is true , whether it's happening in the bedroom , or in the clinic . Of course, when it takes time in the bedroom , no one complains ! When it takes time in the clinic , patients are unhappy and demand answers, which doctors are forced to then cook up.  The tragedy is that these unnecessary tests create lots of red herrings – and patients end up wasting a lot of time doing useless tests and pursuing unproven treatments ( such as anti TB for a positive PCR; or a course of immune therapy for treating abnormal NK cells).

Ideally,  the doctor and the patient should medically analyze how the cycle progressed – and if everything went perfectly like clockwork, the best option is to repeat the treatment without making any changes at all. On the other hand, if there was an identifiable problem ( for example, a technically difficult transfer ; or a thin uterine lining ; or a poor ovarian response), then this is something we can try to treat until you do have a perfect cycle . If you do have a perfect cycle and still don’t get pregnant , then please do not panic. There’s a lot of pressure to do something different the next time, and you might find yourself scouring the internet, looking for what you can do differently the next time around ! However, this is not a medically or scientifically appropriate decision , because often just repeating exactly the same thing again may help you achieve success the next time around. If your doctor tells to change something, you need to look for logical reasons why he is asking you to do so.

This is such a gray area , that sometimes doctors will allow patients to make a change, even when we honestly don't know whether this change will help. When we don’t have enough facts , it's perfectly okay to go by instinct , and this is where the patient’s inputs are so important !

This is why Information Therapy is so important ! Patients need to have realistic expectations before starting the cycle, so that even if the cycle fails, they have the maturity to be able to say - We understand that IVF may not work and we were prepared for this before we started .

If you do want to change something, you have 5 options:
Change the superovulation protocol
Change the eggs ( donor eggs)
Change the sperm ( donor sperm)
Change the uterus )( surrogacy)
Change the embryo  ( donor embryo)
Change the doctor.

The new doctor may often play a game of one-upmanship and make you lots of tests, to prove that he is more thorough and more advanced than the old doctor, who did not bother to do these tests !

The important thing is to have a Plan B, so that even if the cycle fails, you do not go to pieces ! You need to be prepared for failure. This gives you a sense of control over what is happening , so that it's easier for you to deal with the uncertainty if the IVF emotional roller coaster ride .

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1 comment:

  1. Anonymous3:03 PM

    Dear Dr,
    Thank you for preparing us for future. Its true we need to have plan B.


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