Thursday, March 23, 2017

Futile overtesting after an IVF cycle has failed.

A failed IVF cycle can be extremely traumatic for the patient because you do it with a lot of hope knowing that that's your best option. It's the court of last resort after all, and when the cycle fails you're world goes to pieces because you're not sure what to do next, you really don't have a backup option. This is why when a cycle fails, the first question every patients asks is, "Why did it fail?" The doctor in an obvious knee-jerk reflex response will say, "Okay fine, we'll run some tests in order to find out."

Now this seems very logical, but actually this is a very poor quality question which ends up resulting in a lot of over-testing and a lot of over-treatment, because the fact of the matter is, we really don't have very good tests to be able to find out which embryos implant, and which don't. This is hardly surprising because you're putting a microscopic ball of live cells into the uterus, it's very hard to track it's fed. Ideally, doctors should be honest with patients and say, "Look we can't answer that question" but obviously patients don't want to hear that question, and very few doctors are mature enough to be, respect their patient's intelligence and share the truth with them, so therefore they will come up with all kinds of possible reasons such as immune rejection, or NK cells, and do all kinds of fancy, exotic, expensive esoteric tests. Which then lead the patient up the garden path because not only do they make a waste a lot of money, obviously these test results are abnormal as they often will be, they then need to be treated.

The irony is really doing anything for any of these abnormalities doesn't really increase the chance of the patient conceiving in the next cycle. Patients need to understand that's easy to ask questions but sometimes the right answer is "We don't know" and in one sense it really doesn't matter because often, all we need to do is to repeat the cycle, make sure the embryos are gorgeous, the endometrium is fine, and the transfer is easy. If we do this a sufficient number of time, the chance of finally getting pregnant are going to be excellent. But it does require a lot of patience, both on the part of the doctor, as well as the patient, and it requires a lot of maturity on the part of the patient to be willing to accept that technology doesn't necessarily have answers.

This of course makes patients very uncomfortable because they want a doctor who's omniscient, who can answer all their queries, and it's not very comfortable knowing that there lots of things which are not in a doctor's control, but we need to accept that human reproduction is not efficient and we need to learn to live with this reality.

I always tell patients, "If there really were a test which would help me to find out why your cycle failed, don't you think I would do the test before the cycle failed, so that I could optimize your chance of getting pregnant and increase your chance of success, rather than wait for the cycle to fail and then do the test?" This is why all these tests after a failed IVF cycle are completely futile and wasteful.

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