Saturday, October 03, 2015

Over-testing after a failed IVF cycle

We find that patients after a failed IVF cycle are subjected to a lot of unnecessary, expensive tests. There are lots of reasons for this over-testing. Patients are desperately seeking answers and they want to know why the cycle failed. They put a lot of pressure on the doctor to provide these answers. The simple truth that we don't know why the embryo failed to implant , because it's not possible for us to track the biological process of implantation after the transfer . How do we figure out what happens to this microscopic living ball of cells once we put it back inside the uterus ? However, the truth is just not good enough for many patients.

This is why doctors are pressurized into ordering a battery of what appear to be very scientific and sophisticated tests , including genetic tests and immune tests , in order to keep the patient happy. Sadly, none of these tests have been clinically validated and most are unproven. However , because patients are so vulnerable and start grasping for straws, they are quite happy when the doctor orders these tests .  This is why we see so many patients who have failed an IVF cycle who do very fancy tests, such as NK Cell testing or ERA ( endometrial receptivity assay ) testing, which checks the endometrial genome. All of these have a plausible scientific basis, but are of unproven clinical value.

Part of the problem of course is that doctors love playing with new tests. They love zebras, and are quite happy to show the patient that they are not leaving any stone un-turned in their search for answers. In fact, the newer the test and the more expensive it is, the happier some doctors are to order it  ! They do this in order to impress their patients about how thorough and careful and up-to-date and modern they are.

Some patients are very impressed with this battery of tests . They believe that the more the money their doctor makes them spend on the tests, the better the doctor ! While it's true that these tests can be very expensive, a lot of patients don't mind spending this money , because they are led to believe that the results will help the doctor to tailor their next treatment cycle, and improve their chances of success.

This line of thinking  is illogical and flawed . If any of these tests were actually helpful, then wouldn't it make sense that these tests should be done for all patients when they start their first IVF cycle , rather than wait for the cycle to fail before ordering these tests?

The reality is that a lot of these tests are of unproven value, but some IVF doctors prey on their patient's emotional vulnerability and desperation for answers . They pander to their patient's emotional demands to keep them happy. After all, it's so much easier for the doctor to just order the test , and then try to " fix an abnormal result " , rather than sit down and explain to the patient why the tests are of limited value , and why there's very little point in ordering them.

After all, the one thing busy IVF specialists have a major shortage of is time. Very few will spend the time and energy to counsel patients that a failed IVF cycle doesn't mean that there's anything wrong with them ; or that the doctor overlooked a potential problem ; or that the doctor has not done a good job. A failed IVF cycle just testifies to the fact that human reproduction is surprisingly inefficient . Just because one cycle fails, doesn't mean we need to do something different in the next cycle. Often, patience and tincture of time are all that a patient needs to achieve success !

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  1. Anonymous4:43 AM

    I am 30 years old and just failed my first ever transfer, which was a frozen embryo transfer (FET). My lining was 8.4 triple striped, and I was on Endomentrin vaginal suppositories 3x/daily. Also, the implanted embryo was graded a 5AA & was PGD tested as normal by CCS. Side note: I had 10 blastocysts biopsied on day 6 and only 4 came back normal, which I thought was SO bad for my 30 year old age. The only reason I did the testing in the first place was to have a better chance of success on the first try. I am devastated to say the least and am now getting a ton of blood panels (clotting and I think some immunology) and a hysteroscopy, even though a saline ultrasound a few months back was normal. Is this testing too much for one FET failure with a chromosonally "normal" embroyo at 30 yo? I have 3 "normals" left so I do not want to do another transfer until we have as much information as possible as to why it may have failed and things I could do differently next FET. One thing I keep thinking about is how my estrogen never got over 200 the entire time I was on Minivelle patches. I just can't seem to understand this failure. Any advice would be greatly appreciated.

  2. This is the problem with overtesting. All the tests in the world cannot override the fact that human reproduction is not efficient

    You just need to be patient, that's all

    Please don't have unrealistic expectations - IVF will never have a 100% success rate. Our technology will always have limitations, and mature patients need to learn to live with this !

  3. Anonymous3:56 PM

    I was asked to do an era test after my 1st IVF failed. the result came in as "Invalid RNA" I have no clue what it means. i do agree with you in a lot of ways that some clinics just give too many tests and the results just come up what you never expected. I will appreciate if you can explain me what this "Invalid RNA" means. Thanks MG

    1. This means that they could not run the test because the tissue send to the lab was "invalid" . Your doctor will need to repeat the test again. It's a useless and expensive test - why are you doing it ?



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