Repeated IVF failure - what next ?

It can be extremely hard for me to counsel faithful patients who have experienced repeated IVF failure in my clinic . Every time I do an IVF cycle for them , I do it with a lot of hope. If it fails, I tweak the protocol, and hope that we will get lucky this time. However, even though everything goes perfectly, the cycle fails again - and again.  When she comes back with a negative beta HCG, it's hard for me to tell her to do next.

Her question is simple enough , "What do I do next ?"  This is hard to answer, because we don't have enough scientific information on which to guide her . Should we change the eggs? the sperms? or the uterus? Or should she change her doctor ? On what logical basis do we make these changes?

It's very easy for me to give advice to my patients, but I need to be thoughtful, and think about the basis on which I am giving them my advice? Is there any scientific  reason for it? Is it just a shot in the dark?

More importantly, I need to provide the patient with actionable alternatives. Often, the truthful answer is that we don't know why the cycle failed, so it's hard to know what to change and why. Nevertheless , she is looking to me for guidance and direction, and this puts me in a quandary.
This responsibility puts a lot of burden on me, especially because I know that I have personal biases. I want to do my best to make sure that these don't colour the advice I give to my patients .

After all, it's my patients who have to live with the consequences of the decision I help them to make. This is why I'd rather they made it for themselves , rather than based on something which I told them. I do my best to share my ignorance and uncertainty with them . This often backfires. I can feel them thinking in the back of their mind - "If the doctor doesn't know what the next step is, then what am I supposed to do? I'm just a poor patient." They feel completely lost.

However, it's very important for patients to provide their personal inputs because they're the ones who are going to become parents. They have to decide, "Am I comfortable with the concept of surrogacy ? Or is adoption a better option for me ? Does using donor embryos make more sense?"

If I have a patient who has failed multiple IVF cycles in my clinic, even though everything seemed to be perfect, then it's my personal belief that  embryo adoption is a better option than surrogacy . I feel the evidence clearly shows that the seed is more important than the soil . This is why 60 year old women can get pregnancy with donor egg IVF - because their uterus does not age !

However, this is my personal opinion - I cannot back it up with scientific proof for the individual patient. It's not something which other doctors may agree with, and it may not be something which the patient is comfortable with.

I can provide a rationale for my advice, but it's obviously based on probabilities which apply to groups of patients - not to the individual patient sitting in front of me. This is why I am aware that the  advice I give has limitations - and I try to emphasise these to my patients .

I need to be able to justify the advice I give to my patients ? It's not enough for me to say, "Look, I'm the doctor - just do what I tell you to."

It's very helpful for patients to get an alternative perspective. This could be a second opinion from another doctor, and I encourage them to do this. They have peace of mind that they have covered all their bases and explored all possible medical options. I also tell them to talk to their spiritual guru if they have one. He has a completely different way of looking at life , and his view maybe much better than my medically reductionist  perspective of making these decisions.

A lot of patients ask, "Is there anything else we can do to pinpoint what the problem is?" The reality is often we can't , and doing pointless test doesn't help. I agree that repeating cycle after cycle is not a very comforting thought. However, something this is what IVF boils down to - a series of hits and misses until you  hit the jackpot.

I tell patients that they need to make a list of all their possible next steps. It's useful to brainstorm; and using a mind map , as well as free flow writing can help you thinking through what your options are, and their pros and cons as they affect your personally.

It's very helpful to take a treatment holiday , so you can clear your mind and start with a clean slate.

No matter what you decide, you still need to prepare yourself for possible failure  - after all, there's no guarantee that even surrogacy or embryo adoption will work.

At some point, you need to ask yourself, "Have I done enough?" If your heart tells you No, then you need to plan your next steps.  You need to be realistic, and accept the fact that you are entering the realm of the unknown . I agree this is scary, but then this is true for so many things in life.  When science doesn't have all the answers, it's perfectly logical to go by what your heart tells you - follow your gut feel !

After all, when you started your first job, did you know how well you'd perform ? Sometimes we make decisions we regret later on, but that's what life is all about. It is always going to be plagued with uncertainties, but we need to keep on doing our best as we muddle along.

It's very helpful to step outside yourself and pretend that it's your close friend who has the problem, and that she is asking you for help. Counsel this friend , and then try to follow the advice you give her .
These can be taxing times, not just for the patient, but for me as well . It breaks my heart when patients who have reposed their trust in me don't get pregnant inspite of our best efforts.
Do remember to step back and take a long - term, perspective. If you survive this trial by fire, not only will your marriage become much stronger, you will be a much better person. You will also make a far better parent , no matter what particular decision you choose to make.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !