Monday, October 19, 2015

When to Bend the Rules in IVF

As a junior doctor you are taught all the standard medical rules.  You know exactly what to do , because this is what your text books teach you , and you follow this.  These are the answers you need to give to the questions on your exam and this is what your seniors expect from you.

However, as you become more senior and experienced, you understand that there are exceptions to all rules,  and that you need to bend the rules for certain patients . It's only when you acquire clinical experience over time do you know when it’s appropriate to bend which rule for which patient.

I recently saw a patient who had a mucinous cystadenoma, which is a benign tumour of the ovary.  She’d had had a laparoscopic cystectomy in the past to remove it.  It recurred again, and she changed the surgeon, who did another laparoscopic cystectomy . It recurred again ( as many of these tumours are wont to do ) and then she wasn’t sure what to do next.  She was worried that the repeat surgery would damage her ovaries, and she was scared that if she underwent another surgery, there would be no normal ovarian tissue left on that side.  The other ovary was normal at present, but she was scared that she could get a mucinous cystadenoma in that ovary as well, and she really wasn’t sure what her next step was.  She’d had multiple consultations, so I sat down and explained to her what the standard treatment approach would be.

A mucinous cystadenoma is a tumour which is benign. It usually requires surgical treatment , when the doctor removes it. This is exactly what she’d done in the past, but hadn’t worked very well for
her , because it had kept on recurring so quickly. This was unusual , which meant she was an outlier, so we had to think of some non standard way of managing her.

This is why I wasn’t keen on her repeating a laparoscopic cystectomy . This wouldn't prevent it from recurring again, and it would damage her ovarian reserve even more. Since hadn’t had any babies as yet , and for her the priority was to have kid right now.  One of the options I offered her was that we do an IVF cycle for her , and before starting her superovulation, we’d go ahead and aspirate the mucinous cystadenoma, so it wouldn’t interfere with the treatment.  Now this is not standard practice by a long shot.  Mucinous cystadenomas are not meant to be aspirated because all we do is we remove the content but we leave the cyst wall behind , so it will collect again.

I knew this, but I also knew that the standard surgical approach had the risk of causing  her more harm than good . For her , the priority was to have a baby and the cyst aspiration would be a temporising measure , which would allow her to get pregnant quickly.  Of course, after she’d had a baby we could then resort to definitive treatment, for example another  laparoscopic cystectomy,  or perhaps even a removal of the ovary which was causing her so much grief.  This meant I had to spend a long time talking to her, explaining to her what the standard practice was; why I was advising something which was unusual; and why I thought that she was the outlier patient who, because of her unusual individual circumstances, needed a solution which was not the standard solution and why we needed to think out of the box in order to craft something which would fit her needs.  Fortunately, she was educated and well informed and her father was a doctor, so she understood the pros and cons of the options and is now in a better position to make the right decision for herself.

I still don’t know what the final outcome will be. I also understand that I am taking a calculated risk in giving her this advice. After all, no one can criticise you if you follow the standard treatment protocol. However, if she agrees with my advice to aspirate the cyst and she then has a problem, she’s likely to be unhappy , and that other doctors will criticise my approach.  But this is one of those risks which I think is worth taking because I’m doing it in the patient’s best interest to maximise her personal goal of being able to have a baby.

This is one of the advantages of being a senior experienced IVF expert  ! Need help in getting pregnant ? Please send me your medical details by filling in the form at so that I can guide you !


  1. Dr. Malpani
    I am a 38 year old female with 2 prior failed ivf cycles. My first I had a 3 day transfer of a morula and a 10 cell no none to freeze. My second cycle I transfered 2 morula on day 5 none to freeze. This is my third cycle and on day 5 I transfered 3 morula and none to freeze the rest arrested on day 6. Do you think I have a chance since I never make it to the blastocyst stage?

    1. I agree the fact that none made it to blastocyst stage is worrisome.
      Can you send me more details about your IVF cycles ? What were the meds which were used for
      superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? What was the endometrial thickness ?
      How many embryos were transferred ?
      What was the embryo quality ? DO YOU HAVE PHOTOS OF YOUR EMBRYOS ? You can see what embryos should look like at
      Can you please send me the printed treatment summary from your IVF clinic ?

  2. Thank you for your reply. I use 375 units of gonal f and 3 vials of menopur. This was a long lupron cycle. 30 eggs were collected 13 mature and 7 fertilizer normally. Lining was above 12 type 1. All embryos look good on day 3 so we are pushed to a day 5 transfer. 3 morula were transfered. I also take ovarion supplements and levothyroxine. After transfer my progesterone was above 60 and estrogen was above 2000. Where can I send the pictures? I will try and get a copy of records asap. My beta is tomorrow.

    1. You can email the embryo photo to me at [email protected]

      By Day 5, embryos should become blastocysts. The fact that they were morulas is worrisome.

      I am surprised that only 13 eggs of 30 were mature. Do you have PCOD ?

      Best of luck with your HCG test !

  3. I do not have pcos. The other two cycles I had around 20 eggs. Those cycles I had a much higher rate of mature eggs around 13. I used the same protocol. The first cycle was antagonist using ganirelix. That cycle I had 22 eggs 16 mature, only 2 transfered by day 3. We switched to long lupron after that and have continued using that method for other 2 cycles.


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