The 7 steps of IVF

IVF seems to be an extremely complicated procedure, and sometimes IVF doctors take perverse pleasure in mystifying it, because they like showing off their expertise. This is why IVF  patients are often completely confused about what to expect. Actually , it's very straightforward and logical, and if you understand this simple framework , you will be able to make sure your doctor's doing the right stuff for you.

 

Remember that all we are doing in an IVF cycle is replicating what should have happened normally in the fallopian tubes - the only difference is that we are doing this in the test tube !

 

1. First is the pre-IVF testing, or the workup. These are simple tests, to make sure whether IVF is the right treatment for you; and what kind of IVF you require ( for example, if this should be IVF or ICSI).

(a). semen analysis for your husband ( to check his sperm count and motility);             

(b)  blood tests for you for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs). 

(c)  A vaginal ultrasound scan on Day 10 or 11 which should check for a. ovarian volume; b. antral follicle count; c. uterus morphology; d. endometrial thickness and texture, to confirm your uterus is normal. 

If there is a problem, then this can be treated prior to starting IVF!

 

2. Second is the stage of superovulation , where the doctor gives you hormonal injections in order to help you to grow lots of eggs. The growth of the follicles is monitored using vaginal ultra sound scans and blood estradiol levels.

 

3. The third step is that of egg collection ( egg retrieval) , where he collects the eggs from your mature follicles, and sends them to the embryologist in the IVF lab, where they are placed in culture medium. 

 

4. Then comes fertilization, where either using IVF or ICSI, the embryologist adds sperm to the egg. 

 

5. Then is the process of embryo culture, where the embryos are grown in the IVF laboratory in the incubator, so they divide and grow , till they form blastocysts. 

 

6. This is followed by embryo transfer, where the embryos are put back in the uterus with the hope that they will implant. 

 

7. The final step is that of cryopreservation (freezing for storage) where the extra embryos can be frozen in liquid nitrogen , so that they can be used for future attempts. This ensures nothing is wasted or thrown away.

 

Once you understand this framework, you will know exactly what your doctor is doing - and why ! Please make sure that your doctor follows all these steps , so that you know that you're getting the best possible medical care. You can't afford to leave everything up to a doctor, especially in this day and age , where there are so many new IVF clinics cropping up all the time . They are run by inexperienced doctors , and managed by their assistants, most of whom don't have a clue as to what is happening !

As an enlightened patient, you need to take charge !

 

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 !

Why measuring uterine blood flow is pointless in an IVF cycle

Lots of IVF specialists monitor uterine blood flow during an IVF cycle. They believe that this helps them to track uterine receptivity, and good flow correlates with implantation rates. This makes logical sense, which is why so many sonographers study uterine blood flow doppler wave forms and the PI ( pulsatility index)

I think this is meaningless.

The fact that the endometrium is growing to a thickness of 8 mm means that it is receiving adequate perfusion - how would it be able to grow without an adequate blood supply ?

This is another one of those measurements which are of no clinical value - but are done simply because we have the technology to do it !

Using the embryoscope to take IVF patients for a ride

Many IVF clinics claim to use an embryoscope to culture embryos in vitro. While this provides great video images of the developing embryos, it has not been proven to improve IVF pregnancy rates. However, patients are quite happy to pay extra for this, because the doctor claims this is the "latest advance", and that's fine.

However, the tragedy is that these doctors actually are just fooling the poor patient, and they never use the embryoscope at all for them - they just claim to !

This is because they refuse to give patients the video generated by the embryoscope ! The absence of the video is proof that the embryoscope was never used !

The tragedy is that patients are still poorly informed, which means it's surprisingly easy to take them for a ride in order to make a quick buck. It's clinics like this which give all IVF clinics a bad reputation !

Mindless IVF overtesting

When an IVF cycle fails because of poor quality embryos, rather than acknowledge the fact that often the result for the poor quality embryos is a poor quality IVF lab, IVF doctors are happy to blame "abnormal genetics" as the cause for the embryo fragmentation.

They then send the poor patient off on a wild goose chase, by ordering expensive tests such as karytotype    ( chromosomal studies) , sperm FISH, and sperm DNA fragmentation, even though these are completely pointless and useless.

The truth is that most IVF doctors understand very little about the limitations of genetic tests, and are happy to pass the buck and clutch at straws by referring the patient to a "geneticist" !

Even worse , some will flat out tell the patient that their poor quality embryos are proof that the sperm or egg are genetically defective, and they need to use donor egg/ donor sperm/ donor embryo !

What can we do differently in the next IVF cycle ?

When an IVF cycle fails, this is the commonest question which patients ask - What can we do differently next  time ?
They naively believe that the fact that the cycle failed means something went "wrong", and if we identify and  " correct" this, the next cycle will succeed.

This is why doctors do lots of tests; and propose lots of new and more "advanced" treatments, in order to improve the chances of a pregnancy.

Here's a list of the tests which may be proposed , to allow the doctor to "investigate" the reason for the failed implantation in more details

ERA
TB PCR
hysteroscopy
Antibodies

The list of "treatments" to fix these problems is equally long

PGS
IVIG
Immune therapy

The problem is this is flawed thinking, based on unrealistic expectations . An embryo is not a baby, and we don't have the tools to be able to drill down and find out why an embryo did not implant.

Yes, we can provide generic reasons such as "poor endometrial receptivity", but these are "waste-paper basket " diagnoses. We can never prove disprove these labels, which is why they don't provide any useful actionable information.

If the doctor transferred top quality blastocysts into a 8 mm trilaminar endometrium, then all you need to do is to be patient and repeat the cycle until you get pregnant. Changing something just for the sake of doing something different is not a good idea.

The problem is that doctors are also prejudiced to doing something "new and different" - partly because they like playing with the newest toys, and partly because they can charge more for doing these .

Also, because some patients will get pregnant after these tests and treatments , both doctors and patients get fooled into thinking that it was the new treatment which resulted in the success. This is the classical "post hoc, ergo propter hoc" fallacy which seduces so many people. The reality is that lots of these patients would have got pregnant even if the doctor had done nothing new !

The rule is simple - caveat emptor ! Don't let the doctor use you like a guinea pig !

Is my IVF doctor taking me for a ride ?

A patient sent me this email.

I am going through an IVF cycle . Egg retrieval has already been done and as per the doctor's report , 10 embryos were formed.. Then we were told that instead of fresh ET , he will.go for frozen cycle , so that ovary comes to to.normalcy, and he started me on 21 days birth control pill. I am upset that he did not explain this to me before we started.

This month in this cycle (as today is day 13) my endometrium has reached only till 6.5 wherein last month it was 9mm. Is this normal?

If the transfer is not done in this cycle will there be a negative impact on my embryos due to prolonged freezing?
What should I do to increase my endometrium layer. Already having 2 x progynova tab  thrice a day..
Please help..am i being fooled by this IVF business? Or.is there something wrong with me?

It breaks my heart when I see how poorly IVF patient are treated by doctors.

A good doctor will define a treatment plan before starting the cycle , and not change this at the last minute,without  explaining to the patient why he is doing so. A good patient will speak up and ask for answers. The trouble is that patients are very vulnerable , and are very scared of upsetting or offending their doctor by asking questions, which is why they are forced to keep quiet. They bottle their resentment, but this comes bubbling forth when the cycle fails, and the reputation of all IVF doctors takes a beating !

If you want to find a good IVF doctor, you need to be a good patient !

Many patients naively assume that all IVF doctors are equally good, while the reality is very different.

However, if's hard for a poorly informed patient to differentiate between a good doctor and a bad doctor - and bad doctors take advantage of a patient's ignorance !

A good doctor will always proactively provide complete documentation of the IVF treatment cycle, including embryo photos. Similarly, a good patient will always demand this as well, and not leave everything upto the doctor's discretion !

Aggressive and trigger happy IVF doctors !

It amazes me how aggressive IVF doctors have become.

I saw a patient today, who had bacteria in his semen culture( a completely pointless and useless test, which should not have been done in the first place.)

Because this did not clear up with antibiotics, the doctor referred him to a urologist, who advised him to do a TESA ( testicular sperm aspiration) in order to prevent any infection of the eggs !

This is uncalled for and ridiculous! When we prepare the sperm in the lab for doing IVF/ICSI, the bacteria are removed as well, so the culture results do not not affect the treatment outcome !

Freezing all your embryos in order to improve IVF success rates.

Patients have traditionally been reluctant to freeze their embryos because they're worried that freezing embryos will cause them to die. However, the reality is that the flash-freezing technology ( vitrification or ultra-rapid freezing) has become so good,  that survival rates are routinely 100% in good labs , when we freeze top-quality embryos.
When patients have lots of embryos, they're quite happy to freeze their spare embryos. They understand that we can't transfer all their embryos at one time, and they don't want to waste their extra embryos. However, the truth is that embryo freezing is even more valuable for women with very few embryos - even those who have only one.
When you have few embryos, each embryo is even more precious - it's literally worth its weight in gold ! Every top quality embryo has the potential to become a baby , but it will implant only if it is transferred into a receptive endometrium.
Now, the problem in  a fresh IVF cycle is that our focus is on helping you to grow lots of eggs, which is why we superovulate you with hormonal injections. While the endometrium looks fine because of the high estrogen levels this causes, its receptivity is often  compromised because of these supraphysiological hormone levels. After all, the primary goal was to grow eggs , not to prepare the endometrium. This means that even though the endometrium may look thick and trilaminar in a vaginal ultrasound scan, it may not be perfect for allowing implantation. This means that even if you put back a top quality embryo in this endometrium, it has a reduced chance of implanting.
This is why we suggest to all our patients that we freeze all their embryos - even if they have only 1-2. If these are top quality embryos, we can pretty much guarantee them that they will survive the thaw, so they aren't taking any risk. We can then transfer them in the next cycle , at which point our exclusive focus is on preparing the endometrium for optimal receptivity . This combination technique is the best method for ensuring that these precious embryos have the best chance of implanting and becoming a baby.
This " freeze-all" option is a standard treatment protocol offered all over the world, and we encourage our patients to opt for this. The downside is that it costs more ( because they have to pay for the freezing and thawing), and takes longer ( because they need to come back the next cycle for their transfer), but it's well worth it !
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 !

Why are my babies dying at 8 weeks of pregnancy ?

A patient sent me this email

Doctor, I have had many miscarriages at 8 weeks of pregnancy. I have no problem getting pregnant, but the last 5 pregnancies have ended in a missed abortion. I am at my wit's end - what should I do ?

Recurrent miscarriages are a very frustrating problem for both doctors and patients ! Patients blame themselves for the death of their baby, and doctors are unable to provide an accurate diagnosis or a reliable solution.

We do know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because these eggs have more genetic abnormalities, because they have "aged" and have genetic defects, which we do not yet have the technology to be able to screen for.

While we do perform basic tests to rule out correctable anomalies, in most patients we are not able to pinpoint the underlying cause, which means we are often shooting in the dark, and the only treatment we can offer is empiric therapy !

You can read more about this at
http://www.drmalpani.com/knowledge-center/articles/recurrentabortion

What was the reason for the failed implantation ?

One of our patients sent me this email.

Doctor,
We were hoping for some detailed response from you which would have given us some comfort as this time we are very very shocked. We believed that the use of donor egg would resolve my egg quality issue but things doesn't seem to have changed.
I clearly remember in my first cycle, at the time of my ET, we had only one embryo left for transfer and which was at morula stage. You had explained the reason for low number of embryos and slow growth was due to the poor quality of my egg, which had failed to provide energy to the embryo to develop. Even when implantation had failed at that time, you had said the reason was poor quality of the egg. So, does this mean that in this cycle, the eggs which were used were also of poor quality which is why we received less number of good quality embryos and also failed implantation?
Another thing which we also recollect from our first cycle is that we were worried whether it was a sperm issue for failed implantation and whether we should we go for some tests like PGD. You had explained that egg quality is generally responsible for poor embryos and that poor sperm quality do not affect embryo quality after ICSI. Hence, the requirement of any tests was also ruled out.
My uterus and endometrium lining was also perfect during this cycle. So what could be the reason for failed implantation this time? This is a big question. We made the toughest decision of our lives to go with the donor eggs but still the question remains unanswered is something which is not acceptable and hence we look up to you for your fine judgement and expertise.
Now, after having failed implantation from the one and only top quality blasto, we don't know how those two remaining frozen embryos will help if its not from a good quality donor eggs because we don't want to build any hopes for something which is having very little chance of success. 

This was my answer.

These are good questions - but no one in the world can answer them, sorry, so you will have to accept the fact that  reproductive sciences have limits
There are certain things we can control - and lots we can't, and we need to learn to live with this uncertainty and unpredictability
Yes, we could lots of useless tests for you, but none of them would answer any of the questions you are asking
Please have realistic expectations of what medical science can do for you
I would suggest you might want to get a second opinion from another IVF doctor, so you can reassure yourself that we are providing you with good quality care
We do want to give you a baby, which is why we  reduced our fees for you - but we have no control over implantation, which is an in utero biological process
Yes, I would suggest you transfer your frozen embryos, but there is no certainty they will become babies. However, if you do not transfer them, it is 100% certain they will not become babies !

Please remember the Serenity Prayer
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.
I did try to call you, and will be happy to answer any questions, but please understand that we don't always have answers - I wish we did !

Why don't IVF patients insist on embryo photos ?

All IVF patients know that the only tangible product an IVF clinic can deliver is embryos.  After the embryo has been transferred into the uterus, the doctor has no control over the implantation process. This is a complex biological phenomenon, and is impacted by many variables, most of which we do not understand.

This is why it's so important that IVF clinics provide embryo photos to all their patients - so they can prove they have provided high quality medical care, irrespective of the outcome of the IVF cycle ( which is not in anyone's control). This is good for both the doctor and the patient, and is a practise all good clinics follow all over the world.

In this day and age, when so many IVF patients from India spend hours on google in order to learn about IVF, it continues to amaze me why even these articulate, well-read, highly educated , assertive and affluential women don't insist on their IVF doctors giving them photos of their embryos prior to transfer ?

Is it because they are scared to speak up ? Because they are women ?

Would it help if their husbands took a more active role ?

What is a Grade A embryo ?

It breaks my heart when I see the poor quality of IVF treatment today most patients get today.

There is no transparency or openness, and no SOPs ( standard operating procedures). Everything seems to be done on an ad-hoc basis, depending upon the doctor's whims and fancies.

Thus, many doctors tell their patients they have transferred  Grade A embryos for them. The patient is very happy, because she is very impressed with how good the doctor is !

However, the doctor does not bother to provide any photos of the embryos, and it seems that the patient is forced to take the doctor's word for the quality of her embryos.

Good IVF clinics routinely and proactively provide embryo photos to all their patients ! Not only does this increase the patient's confidence level in the clinic, it also helps to document that they are providing high quality care - something which all good clinics are proud to do !

Is normal pregnancy possible after failed IVF treatment?

A patient sent me this email - 

Is normal pregnancy possible after failed IVF treatment? 

Patients often go to pieces after their IVF cycle fails. This is partly because they have very unrealistic expectations of IVF technology; and partly because their IVF doctors mislead them.

When  IVF clinics want patients to sign up for an IVF cycle with them, they are in "sell-mode" , and make all kinds of unreasonable promises, to convince the patient to come to them for their IVF treatment.

For example, the doctor is very bubbly and cheerful at the time of the embryo transfer, and tells the patient that all their embryos are Grade A and their chances of success are 90% . Patients are obviously thrilled, even though the doctor is clearly lying -and has not even bothered to give them photos of their embryos !

To add insult to injury, when the cycle fails, the doctor blames the patient, saying that she didn't rest enough; or that her body "rejected" the embryo !

The truth is that the commonest cause for IVF failure in India today is poor quality IVF treatment !

Many patients can and do get pregnant after a failed IVF cycle, especially if they have unexplained infertility; or medical issues  such as PCOD, which can be treated with simpler alternatives !

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 !

Information Therapy for Patient Education