Tuesday, March 07, 2017

Why we should do only Day 5 transfers for poor ovarian responders

Lots of clinics do Day 5 ( blastocyst)  transfers, but they  usually reserve them for patients with a good ovarian response - patients who have good eggs and lots of embryos , because they're pretty confident that they will get Day 5 embryos. However, they will use double standards when they're treating patients with diminished ovarian result. These are patients who have few eggs and few embryos and they're very scared that they may not get any blastocysts. This is why they will usually transfer their embryos on Day 2 or Day 3. These justification for this is as follows - If we only have two embryos on Day 3, then why bother to grow them in vitro to Day 5?  Let's go ahead and transfer them on Day 3 itself.
Interestingly, these doctors agree transferring blastocysts is a better option. Blastocysts have a better implantation rate as compared to Day 2 or Day 3 embryos; and blastocyst culture allows the doctor to choose the best embryos to transfer.
Their argument is that if you only have two embryos, then a blastocyst transfer offers no advantage as far as selection is concerned . The reality is that they don't want to risk taking the chance that the patient may not have a transfer at all, if  her embryos arrest in the IVF lab between Day 3 and Day 5.
I think this is very shortsighted. If an embryo is going to become a baby when you put it back in the uterus, it first has to form a blastocyst inside the uterus. If the IVF lab is decent, then if it's going to form a blastocyst in the uterus, then of course it will form a blastocyst in the lab as well.  They why is the doctor scared about growing this embryo in the lab? Is it because he doesn't have enough confidence in his lab?
Another argument which has been trotted out is that growing to blastocyst doesn't improve pregnancy rates in these patients with poor ovarian reserve. This is flawed , because the point of an IVF cycle is not just to improve pregnancy rates.  The truth is that the pregnancy rate will remain as good even when you grow them to blastocysts in a good lab, so this will not reduce the pregnancy rate. However, much more importantly , you're also utilizing the IVF cycle to provide valuable information for the future.  Let's look at this more carefully.
If the patient gets pregnant, that's a happy ending, irrespective whether you did a Day 2 or a Day 3 or a Day 5 five transfer, so there's no point in discussing that outcome. But if the patient doesn't get pregnant after you transfer a single good embryo on Day 3, then the poor patient is not sure what to do in the next cycle.  She is not sure why her cycle failed because you transferred so early. Why did the embryo fail to implant? Was it a problem with the embryo?  Did it arrest inside the uterus after the transfer ? Or was it a problem with the uterus? Should her next step be surrogacy? or should it be donor egg IVF ?
She's completely confused, especially since you've made a good Day 3 embryo for her . You have sparked some hope in her heart, and she was very hopeful that the embryo you put back would become a baby. Not only has she had to suffer through that terrible two week wait, she's actually no wiser as to what to do in her next cycle.
On the other hand, if you had the courage to grow the embryo to Day 5, and if it had arrested in the lab, you could tell her, "Look, the fact that it arrested in the lab means it would have arrested in the uterus, so you really haven't lost a chance at getting pregnant. This embryo was never destined to become a baby in the first place , and this is most probably because of a genetic defect in the embryo, which prevents it from growing further. More importantly, we've also obtained extremely valuable information . We now know for sure that the reason for your infertility is your poor egg quality. We've proven it to you , because your embryos has arrested in vitro. I know this is painful, but if you are willing to use donor eggs the next time, your chances of getting pregnant are going to be much better."  Now that she's seen for herself that her embryo has arrested in the lab, she's much more likely and willing, both emotionally and logically, to accept the option of donor eggs.
I think it's important that IVF doctors learn to take a holistic view of IVF treatment,  and not think of it only in terms of a single cycle. Yes, you could transfer the embryo on Day 2 and pat yourself on the back that you managed to reach the stage of embryo transfer. The patient is also happy with you , that at least you managed to create an embryo for her.  And when her cycle fails, you can make the diagnosis of "failed implantation"; make money by doing lots of very expensive ( and useless) tests; and then advice surrogacy !  Doing the transfer on Day 3 is a copout because it takes the pressure off you - but is not in the patient's best interests ! Some labs compromise by doing a sequential transfer - transferring some embryos on Day 3, and the some more on Day 5. This makes no logical sense at all, and just increases the risk of a multiple pregnancy.
On the other hand, if you have the courage to grow her embryos to Day 5,  and then it arrests  in the lab, she's going to blame you. You are going to have to give her a shoulder to cry on, and it's no fun having to console patients who are sobbing because their embryos have arrested. But in the long run, this is the right thing to do for the patient.
Finally, even though the numbers are very small, I believe this approach will improve pregnancy rates . We all know that the best place for a Day 3 embryo is not the uterus - it's the fallopian tube or the IVF lab. We were forced to transfer Day 3 embryos into the uterus in the past, because we were compelled to take a shortcut , since our laboratory technology was not good enough to grow embryos to Day 5 reliably . However, with today's advanced technology, when lab conditions are so much better , I don't think this is justified anymore. Just like a plant needs both a good seed as well as good soil, it's important to synchronise the embryo and endometrium when doing IVF - and the right stage for the embryo to reach the uterus is Day 5. A transfer earlier than this is a compromise, and not in the patients best nterests.
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 !

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