Saturday, September 30, 2017

Empirical therapy in IVF - good , bad and ugly

Doctors are very fond of prescribing treatments, and a lot of these are empirical - based on their personal clinical experience. This is especially true in IVF , because there's so much we don't understand about reproductive medicine. Thus, when we say someone has failed an IVF cycle because of " failed implantation" , this is just a label to disguise our ignorance , because we cannot study embryo implantation in utero.

The truth is that we have no idea why the embryo failed to implant, but patients don't want to hear the truth. This is why doctors don't want to admit that we are clueless ! The patient is very anxious, and if you acknowledge you are not sure , the patient will go hunting for a second opinion, because they want a doctor who can inspire confidence !

This is why empirical therapy has become so prevalent.  Empirical therapy simply means therapy based on experience. Its efficacy hasn't been verified by controlled clinical trials , because these are quite expensive .
Empirical therapy is of two type - good and bad.  Good empirical therapies are usually cheap, inexpensive, short-term and have no side effects. Thus, prescribing a 15-day course of antibiotics for a patient whom you suspect has endometritis is unlikely to do much harm.  Yes, it may not help, and that's something the patient needs to be aware of.

The big problem is that there a lot of very expensive empirical therapy as well, some of which can be harmful. Thus, many IVF specialists put all their patients on 9 months of anti-TB treatment based on unreliable TB PCR tests . Patients are subjected to expensive, time consuming treatment which can have a lot of toxicity - and this also harms the community by causing the spread of drug-resistant TB. You can read more about this at

Lots of other "treatments" are very expensive , and have many side effects . These include stuff like intravenous immunoglobulins ( IVIg); paternal lymphocyte immune therapy for treating " high levels of NK cells" ; intralipid infusions; and  PGS. It's a long list and that's why it's very important to explain to patients before starting  that this is therapy which has not been proven. The doctor needs to be honest and say, given the fact that we have limited options, we'd like to try this on you . However, we need to get informed consent from patients that this is treatment which has not been established as being scientifically sound because we don't have enough data, but if you want to try it, we're happy to go ahead and do this for you.

Sadly, most doctors don't do this, which is why IVF patients end up wasting so much money on wasteful and useless tests and treatments.

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