IVF video - Good IVF clinics vs Bad IVF clinics

Before you see your IVF doctor - practical tips every IVF patients need to know

Since you only have a few minutes to spend with your IVF doctor, it's important to be well-organised, so that you can make the most of your precious time with him.

Do your homework online, so you can ask intelligent questions, tailored to your particular circumstances.

The only stupid question is the one you don't ask !

Here are some practical tips

It's great see that medical labs are getting digitized, and patients carry their medical reports with them as soft copies on their phone , where they are easily accessible. However, whenever you go for a consultation with your doctor , please make it a point to print out all your reports and organize them in reverse chronological order .

This helps you to make sure you are well organized, and haven’t forgotten anything.

It’s also much easier for your doctor to review all your reports . If he wants to see a particular report and you can't find it because there's too much garbage on your phone , this makes you uncomfortable , and the doctor starts getting irritated because you're wasting his time .

It’s also a good idea to prepare a one-page piece summary of all your medical treatment , diagnostic procedures , and test results . This gives the doctor a bird’s eye view of what you have been through .

It also shows that you're well organised , so your doctor will respect you more.

Please be proactive in your IVF treatment , because you cannot afford to leave this upto chance.

IVF treatment is expensive , and the outcome is always uncertain, which means you can never be sure how many cycle you will need to get pregnant . After some time, the details of the earlier cycles will start getting blurred, and you don’t want to provide incorrect information to your doctor .

Finally, please listen to your gut when deciding which doctor to go to. 

The good news is you have lots of choices.

The bad new is you have lots of choices

This is why it can be hard to select who is right for you. Seeing how well your doctor answers your questions will help you select the doctor who is right for you.

 

 

IVF video - please do not waste your precious embryos !

 

Why did my IVF cycle fail even though my IVF doctor is the best ?

When I review the records of patients who have taken treatment in other IVF clinics , they often claim that they went to the best doctor in their city – the doctor who is the finest , and is the best IVF expert available.

This is because they need to rationalize the decision that the doctor they selected was the right doctor , even if it is clear from their medical records that the doctor wasn't good because he did not provide high quality medical care . He did not even bother to provide photographs of the embryos he transferred.

There is a lot of emotional discomfort as a result of cognitive dissonance when patients realize they were taken for a ride by their IVF doctor. They kick themselves because they selected a bad doctor because they did not bother to do their research .

Patients don’t like confronting this fact , and what to continue believing that the doctor they chose was the best – after all, they have already spend tons of money in his clinic, and the truth can be hard to accept.

They take offence when I tell them that perhaps the choice they made was not good, and the quality of care which they got was poor.

While I am not saying that I am the best doctor , all I'm saying is that patients need to be aware that there are multiple different options , and each IVF clinic has their pros and cons .

Unless they are proactive and take an active interest in their treatment by questioning the doctor and being assertive , they're not going to be happy with the quality of care they receive – especially if their IVF cycle fails , by which time it’s too late to do anything about this

 

Previous Caesarean section reduces IVF pregnancy rates

Many IVF patients are subjected to a caesarean section by their obstetrician when they get pregnant, because this is considered to be a “precious pregnancy”, even though there is no real medical reason for them not to have a normal vaginal birth.

The problem is that when they come back for their next baby, the IVF success rates drop because of their earlier caesarean section. The scar on the uterus reduces the chances of the embryo implanting.

The risk is increased if a post-Caesarean scar defect (also called a niche) is seen on the ultrasound scan .  A niche is an indentation of the uterine wall of at least 2 mm at the site of the Caesarean scar, assessed by transvaginal ultrasound .  Some of  these patients also have an accumulation of endometrial fluid around the niche.

The reasons for the lower pregnancy rates after a Caesarean section remain to be elucidated. Some studies suggest that incomplete uterine healing and post-operative infection may play a key role in interfering with embryo implantation

Also, implantation very close to or in the niche increases the risk of a miscarriage, because the niche is not a favourable site for implantation.

Please don't allow your doctor to do a routine elective caesarean section for you ! There needs to be a very good medical reason for performing this major surgical procedure !

 

IVF video - How to interpret your HCG blood report

 

Making sense of your HCG blood test report - a guide for IVF patients

One of the most important blood tests for IVF patients is the HCG test .

This is done two weeks after the embryo transfer , to find out whether the embryo implanted or not – and tells us if your IVF was successful or not . Obviously , a lot rides on it , and whenever patients get their report , the first thing they want to know is if it is positive or negative.

Now making sense of the HCG report is extremely easy , because HCG ( for all practical purposes ) is produced only by the placenta during pregnancy . This means if it positive , you are pregnant - and if it is negative , this means you are not pregnant .

However, we find many patients have a hard time interpreting the HCG level , and this is true for multiple reasons .

The first problem is the lab report format, which is very unfriendly. While the report is medically accurate , it’s full of numbers ( for example, the normal ranges during the pregnancy). This makes it hard for patients to know what the expected normal range for them should be, because HCG levels rise so rapidly during pregnancy , and the lab has to include all the ranges when reporting , because it doesn't know how many weeks pregnant the patient is . Patients only care about their value, and often can’t even find this on the report.

Another big problem with interpreting the HCG level is the fact that there is such a wide range of normal values. This is because HCG levels rise exponentially , which means they double every two days , and the level rises from 300 mIU/ml to 1000 mIU/ml in 4 days !

Patients don’t understand this, because they are much more used to interpreting simple blood tests such as blood sugar levels , or hemoglobin levels , which usually remain pretty much stable over time .

A big problem is also that patients are innumerate, and don't understand how to make sense of numbers . For example, they don’t understand decimals, and when the laboratory reports the HCG level as being less than 0.567 ( which means it’s negative because it’s less than 1), they get confused .

Some patients naively believe that negative equals zero, and that the presence of any HCG in their body means that they must be pregnant – after all, how did this HCG show up if they aren’t pregnant ?

The problem is that a negative HCG level causes a lot of frustration and heartache. It’s hard to come to terms with the truth, and patients are very hopeful that if they repeat it again, it may become positive.

The problem is that false hope can be cruel, and if the HCG level ( as done from a reliable lab ) 12 days after the embryo transfer is negative , this means your cycle has failed , and there's no point in wasting money on repeating the test again .

Another major area of confusion is the weeks of pregnancy reported as part of the normal range on the printed area . Patients are confused , and don’t understand the difference between the menstrual age ( as calculated by the duration from the last menstrual period, LMP) vs embryonic age ( the actual age of the embryo).

While a negative HCG is easy to interpret, a positive HCG is harder to decipher, because a single value means little. We need to repeat the test, to ensure it is doubling every 2-3 days, to confirm that the placental cells are growing well, which suggests a healthy, viable pregnancy

 

 

IVF video - all that glitters is not gold. How to stop wasting your money on the "latest and newest" tests

 

What tests can you do if you have failed multiple IVF cycles ?

 Patients who have failed repeated IVF cycles even though apparently perfect embryos were transferred, are understandably upset, frustrated and distressed. They are looking for answers as to why they are not getting pregnant, and a plausible reason is that their body is "rejecting" their embryos. This is why immune testing for patients with reproductive failure has become very fashionable recently.

Many labs use different protocols to carry out these tests, which are still poorly standardized. This means that results for the same test from different labs vary widely, making interpretation very difficult. 

Also, intelligently interpreting these tests in individual patients is virtually impossible, because of the considerable overlap in the results in normal fertile women and those who are infertile, since many fertile women will also have abnormal results when subjected to these tests. Sadly, most labs do not bother to standardize their test results by doing them on normal fertile women. This means that if a woman who has had an IVF failure is subjected to these tests and has an abnormal result, her doctor happily jumps to the erroneous conclusion that he has now "diagnosed " the reason for the IVF failure, little realizing that the abnormal result could just be a "red herring", since "abnormal " results are often found in "normal " fertile women as well. (These are called " false positives " - test results which are abnormal ('positive'), even though the patient has no disease.) 

The truth is that we can't find the reason why a "perfect IVF cycle" fails because our technology is still not good enough to track the fate of the embryo after it is transferred into the uterus. Embryo implantation is a black box , and is very inefficient.

The problem is that a false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Remember that if your doctor performs enough tests on you, it is a mathematical certainty that he will find something wrong with you. And if he finds something wrong with you, he'll usually end up treating you - whether you need treatment or not !
The only person who benefits by doing these expensive and exotic and esoteric tests is your doctor !

Just Say No if she advises them

There is a long list of expensive tests which many labs now perform - and these include: DQ Alpha, Leukocyte Antibody Detection, Reproductive Immunophenotype, ANA (Antinuclear Antibody), Anti-DNA/Histone Antibodies, APA (Antiphospholipid Antibodies), Natural Killer ( NK) Cell Assay , Pregnancy Destruction Factor and TJ6 Protein. This mind -boggling range of catchy acronyms conceals the fact that no one knows whether the immune system is really responsible for the failure of the embryos to implant in these women. Because these tests are unreliable, they are in vogue for a few years, and then die out when doctors realise they don;t add any value.

IVF success rates and technology - new is not always better and old is often gold !

Like all IVF specialists, we want all our patients to get pregnant in the very first cycle itself . When patients get pregnant, they refer their friends and family members to you – and this is the best source of referrals !

This is why we want to achieve a 100% percent success in IVF , but the problem is that IVF doesn't have a 100% pregnancy rate, and this is a fact we need to learn to live with.

The problem is that false hope is created every time a new scientific advance which is reported as being cutting edge research in described in medical conferences and medical journals. All doctors get excited and want to be the first in India to offer this newest technology. And these researchers also publish press releases to get more publicity, so patients read about the “newest and latest” technique developed in the USA, and want us to use it for them.

However, over time we often find that not everything which glitters is gold , and a lot of the stuff doesn't actually end up working very well in clinical practice .

This is not surprising , because most researchers have a publish or perish mentality , which means they are under a lot of pressure to publish papers, even if their findings are reliable or replicable. Since no one wants to publish negative results , and editors are only interested in publicizing positive results , there is a lot of hype about these “advances”.

These include : the use of growth hormone injections for poor ovarian responders;

• the use of immune testing and immune therapy for treating recurrent IVF failure;
• PAMP and ERA tests;
• Intrauterine infusion of growth factors for improving a thin uterine lining;
• stem cell ( PRP) therapy;
• endometrial scratching to improving endometrial receptivity.

 We tried these out when they were first described, and have stopped using them , because they don’t improve IVF success rates.

The tragedy is that many IVF clinics continue selling these techniques to their patients, simply because they can charge more for every additional procedure they do, even though it's been proven that these techniques don't work well .

This is why it's so important that patients be assertive , and do their own homework for themselves rather than signing up for every technique which the IVF clinic offers to you.

You don’t have to become cynical , but you do need to learn to be skeptical.

New is not always better , and older techniques are better because they've stood the test of time.

The best treatment for repeated IVF failure ( recurrent implantation failure) is TLC !

Some of the most frustrating problems in reproductive medicine today are the ones we do not have the technological tools to be able to make an accurate medical diagnosis for, We call them “idiopathic” – which is medical jargon for GOK - God Only Knows.

This is true for the three categories of the most difficult patients IVF specialists see today.

1. Unexplained infertility , where all the medical tests we do aren’t able to explain why the couple can’t get pregnant in their own bedroom
2. 2.   Recurrent implantation failure , or repeated IVF failure, where the patient fails to get pregnant in 3 IVF cycles, even though we have transferred top quality blastocysts in a receptive endometrium
3. 3.  Recurrent pregnancy loss or recurrent abortion , where the patient gets pregnant , but loses the pregnancies every time , at about 6 to 8 weeks , and we not being able to pinpoint the cause.

Now we have a standard medical work up for all these conditions, which means we do an extensive  panel of tests to try come to a diagnosis. The problem is that usually we can’t find any abnormality !

This is the time when truthful doctors will stop, and confess to the patient that we have reached the limits of modern medical knowledge , and are now entering the realm of medical ignorance . Doing more tests will not help, and further testing should only be done by researchers who are doing controlled clinical trials. After all, it is not fair to treat patients in an IVF clinic as guinea pigs .

However, patients are not happy with this answer , and want more tests done – the more, the better ! Doctors are happy to oblige, because these tests are expensive, and very profitable for them to do. Also, doing tests conveys to the patients that they are being “thorough and careful”.

However, the truth is they provide no useful actionable information . What’s even worse is they are plagued by false positive results, which means doctors make patients waste a lot of time and money chasing red herrings.

Ideally, the doctor should be humble and honest,  and explain that there is nothing further medical science can offer them, and we have done everything humanly possible, which should give patients invaluable peace of mind that no stone has been left unturned. After all, medical science has its own limitations .

This doesn’t mean that we are helpless, and there is still hope for the patient – we aren’t writing them off or refusing to treat them.

Going forward, the two most important tools are – patience,  which means we keep on doing this until it works ; and the most important therapeutic ingredient is TLC,  or tender loving care !

This might sound surprising , because TLC doesn't seem to be a medical treatment which anyone could prescribe , but nevertheless it is one which has been proven to be extremely effective ! In fact , it's been shown to be far more effective for patients with recurrent pregnancy loss , as compared to additional experimental treatment options , such as PGT or immunotherapy . And the best thing about TLC is that it’s free !

 

Why you cannot afford to be a lazy IVF patient

In a perfect world , every IVF clinic would have a high success rate ; and every IVF doctor would be ethical and would tell patients the truth , and provide high quality treatment.

The reality is we don't live in an ideal world , and you can't afford to live in a fantasy land and hope that your doctor is the best .

The problem is that doctors come in all shapes and sizes , and most patients are too lazy to do their own home work , or invest in Information Therapy , to try to differentiate between a good doctor and a bad doctor . This will come back to haunt you, if are unlucky enough to end up in a bad IVF clinic because you were lazy.

This wastes your time , money and energy - and more importantly , it will result in your losing confidence in all IVF doctors , because you had a bad experience with one bad clinic. The burnt child dreads the fire , and you are naturally very reluctant to try another cycle in a better clinic.

This is why you can't afford to be passive . You need to do your homework , because you need to be a good IVF patient if you want to find a good IVF doctor .

The good news is it has become very easy for you to do this . There is plenty of information available online , and while much of it is poor quality, you can get high quality reliable information at www.drmalpani.com.

This way, you will learn what IVF global best practices are, based on scientific evidence-based guidelines, so you can check whether your doctor is following them or not .

If he isn't , this is a red flag , and you should walk out from the clinic as fast as possible , before wasting more money .

Yes, it's true that you cannot control what your doctor does , but you can control which doctor to go to !

This is such an important decision that you cannot afford to be sloppy about this , because this is something which you may regret afterwards

 

Please do not waste your precious embryos

When the IVF cycle goes well and the clinic makes many embryos, patients are excited and want the doctor to transfer as many embryos as possible , so that they can get pregnant quickly . They understand that their chances of getting pregnant improve when they put more embryos back , but actually this is very short sighted .

For one thing , it dramatically increases their risk of having a multiple pregnancy , which gives short-term joy, but causes long-term distress, because many of these end up as preterm births, and many premature babies are often plagued with life-long problems ( such as retinopathy of prematurity, and cerebral palsy). Of course, the IVF doctor doesn’t care, because he can notch this pregnancy up as one of his successes, but want IVF patients want is a healthy baby – not just a pregnancy !

 Also remember that if you transfer all your fresh embryos back , you will not be able to freeze any. This means that if your cycle fails, you be left with any spare embryos, and will be back to square one , and will have to start a new fresh IVF cycle all over again . This is profitable for the IVF clinic, but very expensive and stressful for you.

 We tell our patients that each of your embryos is worth their weight in gold , and it makes much more sense to transfer just one embryo at a time , so that you can have multiple attempts at embryo transfers after doing a single egg collection.

The cumulative success rate is actually much better , because transferring frozen embryos is much easier , much less expensive , and much less stressful than starting a fresh cycle,

Remember that putting more embryos back does not increase the chances of a particular embryo implanting, which is why it makes much more sense to actually transfer your embryos over multiple cycles , rather than to dump them all back in a single cycle . If you get pregnant and end up with a multiple pregnancy , this is a bad outcome . And if you don't get pregnant , that's a bad outcome as well !

What you need to do to minimise your bad outcomes and increase your chances of having a good outcome is to freeze all your spare embryos , and transfer only a single embryo at a time

 

Why pooling embryos is not always a good idea for IVF patients

 

It might seem surprising , but IVF doctors also seem to fall prey to fashions , many of which come and go .

One of the popular strategies which many IVF doctors use today is that of embryo pooling, but this is often the wrong option for many patients.

When the patient has only one or two good quality embryos in their fresh IVF cycle, instead of transferring it, doctors tell patients to freeze them , and do 3-4 fresh IVF cycles back to back, so they can make more embryos, freeze them and store them – a process called embryo pooling.

Patients are happy to do this, because they feel that if they have more embryos, their chances of getting pregnant improve.

While this makes intuitive sense, it’s not a good idea for young patients who are poor ovarian responders. The way to maximize chances of getting pregnant is not to transfer many embryos at a time ( a tactic which unnecessarily increases the risk of a multiple pregnancy) , but to transfer a single embryo , as many times as possible.

Thus, if you have a good quality blastocyst, and your uterine lining is receptive, you should transfer the embryo back in the fresh cycle itself. If you get pregnant, you don’t need to do anymore cycles , until you want your second baby !

And even if you don't get pregnant , you are better off starting a new fresh cycle.

However, for older patients for whom time is at a premium, it makes sense to do 3-4 cycles back to back, so that you can create enough frozen blasts, and transfer them back one at a time. For these women, having more blasts to transfer helps to improve their cumulative pregnancy rate.

For others, transferring a single embryo in the fresh cycle , or transferring the frozen embryo in the next cycle will not affect IVF success rates.

The point is that one-size-does-not-fit-all , and you need to be able to customise your doctor’s advice, based on your particular situation

 

My blood boils when I see IVF doctors fool IVF patients

 A patient asked me for a second opinion about her IVF cycle.

Her cycle had failed, and she shared the photos of the embryos which her doctor had transferred.

These were Day 3 embryos, which had been frozen. The doctor had thawed them and then transferred them on Day 4. He claimed these were good embryos, and had started compacting and cavitating.

This is clearly a lie.

These embryos have arrested, and the cells are dead

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

They should never have been transferred because there is no way they could become a baby.

Sadly, doctors continue transferring dead embryos and fooling their patients.

When the cycle fails ( as it's bound too, because the embryos are dead), they then ask the patient to do a panel of expensive exotic and esoteric tests ( such as ERA and PGT), so they can make even more money by exploiting the poor patient's ignorance.

These are the days when I am ashamed to be a doctor !

Why is your doctor transferring so many embryos at one time ?

Because I offer a second opinion to so many patients , I get a chance to review medical records from IVF clinics all over the country. It’s interesting to see what a large difference there is between good IVF clinics and bad IVF clinics . Many clinics routinely transfer 3 or 4 or even 5 embryos at one time , and patients are very happy that their doctor has made so many embryos for them, and put them back in, thus maximizing their chances of getting pregnant.

Actually, transferring so many embryos at one time is the hallmark of a bad clinic . This is a red flag , and suggests this is a poor quality clinic .

There is no reason why a clinic should have to transfer so many embryos in order to achieve a pregnancy . The fact that they need to do so suggests their embryo implantation rate ( pregnancy rate per transferred embryo) is poor . To compensate for this , they transfer many embryos at a time – they try to compensate for their poor quality by increasing the quantity.

Sadly, not only does this not work, it’s actually very dangerous exercise , and reduces the live-birth rates for these patients .

Sadly, patients don't seem to understand this .

For one thing, this strategy increases the risk to their baby. If they do get pregnant , there is a high chance that they may end up with a high-order multiple pregnancy . Now many patients seem to believe that having a twin pregnancy is a great outcome , but it’s not, because of the risk of prematurity . You may enjoy your pregnancy, but if your babies are born preterm, they may end up with lifelong medical complications as a result of their prematurity. If you have triplets , this risk is magnified even more, because we can’t control implantation . Your pregnancy may give you short-term joy, but your baby may end up giving you long-term sorrow, because of complications such as cerebral palsy or respiratory distress .

Also, remember that every embryo which the doctor transfers means that is not able to freeze that embryo. Which means if your cycle fails, you have no spare embryos to transfer, and are forced to start a fresh cycle all over again ! This strategy helps the doctor to make more money, but reduces your cumulative pregnancy rate per fresh IVF cycle !

Remember that every embryo is worth their weight in gold , and it makes much more sense to transfer just a single embryo at a time , rather than to bung them all back in together .

This is what global best practices are, and all good clinics worldwide transfer only a single top quality blast at one time , so that over a period of two or three cycles , your cumulative pregnancy rate rises, you don't run the risk of a multiple pregnancy

 

IVF success rate - Clinic success rate vs patient’s individual success rate

 

The IVF success rate seems to be such a simple number to calculate – after all, how hard can it be to determine the chances of a patient getting pregnant ?

 While it’s easy enough to calculate the success rate for an IVF clinic ( the number of babies/ number of IVF cycles done), the problem is that most IVF clinics in India fudge these figures and lie about them. They quote an extremely high pregnancy rate – and this is a number they make up, because they aren’t accountable or answerable, and it’s impossible for the patient to verify this, so they can and do get away with making all kinds of all claims.

The bigger problem is it’s much harder to calculate the success rate for individual patients !

This is because each patient does more than one cycle, and they care about their cumulative pregnancy rate. For them, it doesn’t matter much if they get pregnant in the first cycle or the third cycle, as long as they have a baby to take home !

The truth is that patients don't really care about the clinic’s overall success rate – they only care about their personal success rate. Now it’s easy to determine this after the IVF cycle is complete, because after the success rate is either 100% or 0% for the individual patient .

However, patients want the doctor to predict what the success rate is going to be before they start the IVF cycle, and this can be extremely hard ! Each IVF cycle gives us valuable prognostic information, which we can't obtain by any other test.

For one thing , our technology is not good enough to be able to provide accurate predictive figures for the individual patient , because of the law of small numbers. The outcomes of individual IVF cycles are too uncertain because of the multiple complex biological variable involved.

Another big issue is that doctors often make up these numbers . Because they want the patient to take treatment with them , they will quote all kinds of ridiculous figures , and there is no way of the patient finding out whether what the doctor is saying makes sense or not . Because the patient so desperately wants to get pregnant , they are willing to accept at face value everything the doctor says for them . Many patients naively believe that the higher the number the doctor quotes, the better the doctor ! This ignorance comes back to haunt them later on , when the cycle fails .

Finally, remember that as a patient, you should focus on the cumulative success rate – the chances of getting pregnant in 3 embryo transfers. In clinics like ours which do only a single blastocyst transfer, and freeze all the spare embryos, you can do 3-4 embryo transfers after doing only one egg collection – which means your overall success rate is much higher, as compared to a doctor who puts all your embryos back in the fresh cycle, because if this fails, you have no further embryos to transfer, and need to start a fresh cycle all over again.

Ectopic pregnancy after IVF . How to make the diagnosis early to deal with this ticking time-bomb

 

When patients get pregnant after an IVF cycle, they are usually on top of the world . After all, the doctor transferred the embryo back in the uterus , and now they will have a baby after 9 months.

However, when they find out that the pregnancy is not in the uterus but in the fallopian tube ( what is called an ectopic pregnancy ), they have lots of question .

As Google will tell you, an ectopic pregnancy is potentially a life threatening problem , and they are upset and confused and distressed.

Doctor, how did it end up  in the fallopian tube when you transferred it into the uterus ? Did you transfer the embryos with too much force ? Or was it because the tip of the catheter was positioned very close to the cornual end of the fallopian tube ?

The reality is that when we do an embryo transfer , even under ultrasound guidance , once we put the embryo back inside the uterine cavity , we cannot stop it from travelling in any direction it wants to. Rarely, instead of implanting in the endometrial cavity ( where they are supposed to because this is where we deposited them), reverse peristaltic contractions of the uterine muscles force the embryo into the fallopian tube . They implant here, and this is when the patient ends up with an ectopic . While the risk of an ectopic pregnancy is not increased just by doing IVF, the risk is increased in those IVF patients who have tubal factor infertility ( where their tubes are damaged) because they have a increased risk of having ectopic even if they got pregnant on their own.

Sadly, we can’t prevent this,  which is why we monitor an early IVF pregnancy so carefully.

Some patients wonder if we can push the ectopic pregnancy into the uterus . Sadly, this is not possible, because once it has implanted in the tube, this means the fetus has established its blood supply from the tubal blood flow, and if we try to dislodge it, the fetus will definitely die .

 The early diagnosis of an ectopic today is made by exclusion, and we need both HCG levels as well as ultrasound scans to do so. The diagnosis is made when we can’t see the pregnancy sac in the uterus , even when the HCG level is more than 1000 mIU/ml.

Patients find this confusing.  Doctor, why can’t we wait until the sac is seen in the tube ? They are hopeful that the diagnosis is wrong, and that the sac will magically appear in the cavity if we are patient. The reason we can’t wait is because the fallopian tube wall is much thinner than the wall of the uterus, and if we wait until the sac becomes big enough to see in the tube, there is a real risk that the tube may rupture, resulting internal bleeding and shock.

The reason it’s much easier to see the pregnancy sac when it's in the uterus as compared to the fallopian tube is because an early  pregnancy ( gestation) sac consists of mostly fluid , which means the acoustic contrast between the fluid in the pregnancy sac and the solid muscle of the uterine muscle is very high. However, when the pregnancy sac is inside the fallopian tube , it will have to become much larger to be seen, because the fallopian tube is surrounded by other fluid filled structures , such as the intestine. However, we do not have the luxury of waiting, because if we make the diagnosis early,  we don't need to do surgery to remove the ectopic pregnancy , and can kill it by using an injection of methotrexate , which is an anticancer drug . Just because it is also used for treating an ectopic pregnancy doesn’t mean that a tubal pregnancy is a form of cancer . It’s just that the cells in an early pregnancy multiply rapidly, which is why a single injection of methotrexate is enough to kill them, without harming any other organs in the body.

 

If you are unlucky and do end up with an ectopic after IVF, you might want to request your doctor to surgically clamp your fallopian tubes by doing a laparoscopic clipping near the corneal ends, before doing the next embryo transfer , because the risk of having a repeat ectopic in your next IVF cycle will then become zero.

 

The biggest danger of a delayed diagnosis is that if the ectopic pregnancy grows , the pregnancy sac can cause the fallopian tube to rupture, which could risk the mother’s life because of internal bleeding, which is a completely preventable medical catastrophe.

 

IVF vs adoption. How do you make the right decision ?

 

Why don't you adopt ?

This is one of the commonest pieces of gratuitous advice given to infertile couples who have failed IVF treatment . It may be well-meaning, but causes enormous distress.

It’s not as if IVF patients don’t already know that adoption is an alternative to IVF to having babies, and the entire idea of thinking that IVF and adoption are competitive ways of completing your family makes absolutely no sense to me .

These are complementary choices , and it's up to the infertile couple to decide for themselves what works best for them.

We tell couples to keep an open mind , and explore all their options . In fact , we suggest that they explore them in parallel , and register their name for adoption while doing their IVF treatment . During this journey, you may find that it's far better adoption than doing IVF, in which case you can go down that route. On the other hand , you may find that the adoption process is not right for you , and therefore you can new invest all  your energy in doing more IVF cycles , since you have determines that this is your preferred option .

I hate other people advising infertile couples as to why they should be adopting rather than doing IVF . This is extremely judgmental , unkind and unempathetic . In one sense , these people make IVF patients feel they are being selfish, when they prefer to spend money on IVF, rather than on adopting a baby. They perceive adoption as a better choice – one which is big-hearted and generous , because it helps an unwanted child .

This makes no sense to me . You should be making your own decisions for yourselves, and you should ignore everyone who doesn’t walk in your shoes.

Couples who choose to adopt for themselves are extremely happy with their  choice, but those who are forced to adopt – either because their IVF cycles failed or because of social pressures - end up being miserable. If you are miserable yourself , you are never going to be able to keep your adopted child happy , which means you end up creating more misery , rather than increasing joy .

This is completely counterproductive .

Both IVF and adoption are long-drawn processes , for which you need the help of professionals. Each option  has pros and cons , and it's up to the couple to decide what works best for them . These aren’t mutually exclusive , and you need to look within your heart and your gut to decide what works best for you . Please don’t close your mind and refuse to look at alternatives. The more the options you have in front of you , the easier it is to remain in control of your decisions, rather than despairing just because the IVF cycle does not work

 

Should you change your IVF doctor ? Or change your eggs ? The option for donor egg IVF

When an IVF cycle fails , the patient is naturally upset and distraught. They ask the doctor for advice as to what they should do next , and often many doctors will tell them to use third party reproduction options , such as donor eggs or donor embryos,  especially when the number of eggs which were collected was few, or if the embryo quality was poor. It's also much more profitable for the doctor to advice third party options, even though this may not be in your best interests.

Because patients are so desperate to have a baby, they are quite happy to follow the doctor's advice , but the truth is that instead of changing the eggs ( by using donor eggs),  you may actually be better off by changing the doctor !

This is because the poor ovarian response may have nothing to do with your biological problem at all. It maybe a result of the fact that the doctor did not superovulate you well – a common problem when it’s the junior doctors or assistants who are in charge of the IVF treatment, and they use rigid standardized protocols to treat all their patients.

Also, if the quality of the IVF lab wasn't very good , this will also cause your embryos  to fragment, and they won’t grow properly , because the embryologist does not know how to nurture them well.

This is why, before changing your eggs ( or your sperm , or embryo or uterus in your next IVF cycle ), first consider changing your doctor .

It’s a very good idea to get a second opinion from an independent expert, before making such an important decision .

When you ask for a second opinion , please make sure that you get all the medical records of your first IVF cycle , including photographs of your embryos, so that the specialists providing a second opinion can guide you as to what you can do differently to maximize your chances of getting pregnant with your own eggs , your own sperm , and your own uterus .

While using donor eggs is always an opinion, this should always be Plan B, after you have finished exhausting all your alternatives.

Why do embryos fragment in the IVF lab ? What patients need to know about embryo grading

 

Patients know that their chances of getting pregnant depend on the quality of their embryos, which is why they get excited when they have top quality blastocysts.

However, when their embryos start fragmenting, and are graded as being poor quality by the embryologist, based on their morphology ( cell fragmentation occurs because the cells of the embryo ( called blastomeres) don't remain viable) ,they often go to pieces .

You need to understand how doctors grade embryos in the laboratory , and you need to make sure that your doctor provides you with photographs of your embryos, so that other IVF experts can judge the embryo quality for themselves, rather than have to depend upon a  printed report given by an embryologist ,which is impossible to verify because he can call every embryo a Grade A embryo !

Embryo quality could be poor because of poor quality eggs, or a poor quality lab, and it makes a world of a difference what the reason is !

Thus, if you are an older woman with poor ovarian reserve ( a low AMH level and a low antral follicle count), then this could be the reason for poor embryo quality, because poor quality eggs which have aged have dysfunctional mitochondria, which results in impaired cell cleavage.

However, if the reason for the poor egg is iatrogenic – for example, when the doctor does not use the right superovulation protocol to help you grow more eggs, then changing your doctor can improve your chances dramatically.

This is also true for young women with PCOD. Doctors are so scared of OHSS ( ovarian hyperstimuation syndrome) that they end up using a very low dose of FSH ( Gonal-F ) for the superovulation, and they mistimed  the HCG injection, as a result of which they get few eggs and poor quality embryos.

The other common reason for poor quality embryos is a poor quality IVF lab, where the embryologist is not full-time, or is not experienced and does not have enough expertise.

The key take-away message is that the reason for poor quality embryos may not be a problem with you – it maybe a problem either with the clinician , or with the laboratory .

This is why , if you end up with a failed IVF cycle because of poor quality embryos , rather than change your eggs ( as your doctor may suggest ), you may actually be better off changing the clinic .

Find a better clinic who can grow your eggs , and transfer top quality blastocysts for you

The problem with arrogant IVF doctors and the way they treat IVF patients

I have noticed there are two kinds of IVF doctors .

Many suffer from hubris, and these are typically young doctors who believe that they are far better than senior doctors because they are equipped with the latest technology , and have the newest knowledge . They believe they are to do a better job than everyone else , because they are up to date with the latest research . Because they want to deploy cutting edge Technology , they utilize all the latest tests and treatments in order to get their patients pregnant, because they get fooled by all the marketing literature which IVF device manufacturers publish.

However, after a few years, maturity finally dawns , and they realise that just because a test seems promising in a research lab doesn’t mean it helpful in clinical practice. New is not better – and older tests are often better, because they have stood the test of time.

Sadly, some doctors never acquire this wisdom, and continue suffering from “shiny object syndrome”. As they become more senior , they start thinking of themselves as being the court of last resort , and when desperate patients come to them , they want to offer them hope, even if it is false. These patients are often clutching at straws , because they have failed many cycles elsewhere , and they put these IVF doctors on a pedestal . The doctor starts acquiring arrogance, and feels that they are the ultimate experts, who know exactly what to do for everyone who comes to them .

They refuse to acknowledge the reality that so much about IVF is still beyond our control . They refuse to brook dissent , or try to learn from others .

The best , and most experienced doctors , who have a lifetime of clinical wisdom and experience, understand that we don’t have all the answers, and that while IVF success rates have progressive improves , they are not going to reach 100%.

IVF failure is one of the things both IVF doctors and patients need to learn to come to terms with.

Instead of running more pointless and expensive tests or offering unproven treatments, to these doctors provide their patients a shoulder to cry on – an intervention which is far more meaningful and helpful !

What can you do to improve your chances of IVF success ?

 

A question patients commonly ask me is - What can I do to improve my chances of IVF success?

The truth is IVF success in an individual cycle is uncertain and unpredictable . There are certain things which we can control , and many variables which we can't .

Thus, you can control selecting a good doctor , who transfers top quality blasts into a receptive endometrium , but after the blastocyst has been replaced inside the uterus , we have no control over whether that embryo will implant or not.

The fact we have no control over embryo implantation is frustrating both for patients and for doctors as well . When we transfer a top quality blastocyst and it doesn't implant , this can be heartbreaking for us as well, because we are human too, and we want all our patients to get pregnant quickly. After all, this is the reason we became IVF specialists - to help them to complete their family .

At some point ,we need to acknowledge our frailties , and the limitations of our Technology.

There is little point in losing sleep over stuff which he can't do anything about it, because this just results in anxiety and unhappiness , and doesn't help anyone .

While this is an area on which a lot of research is being done , an IVF clinic cannot use patients as guinea pigs !

Patients will often demand the doctor do things differently in the next cycle, and doctors are happy to oblige by doing additional tests , like ERA and PGT , but they don’t help at all, because they are riddled with false positives, and are very unreliable.

 The fact that doctors don’t use these tests routinely for all IVF patients itself suggests they are of limited value. After all, why wait for the cycle to fail before doing them if they really are so useful ? After all, we want patients to get pregnant, because when they get pregnant , they refer even more patients to us, and we would much rather have happy patients with babies , rather than unhappy patients with failed IVF cycles

Finally, also remember that changing your diet , or taking bed rest , or “ relaxing”,  will not improve your chances of getting pregnant . None of these things affect embryo implantation, which is a biological process over which we have no control, and we need to be humble enough to accept this.

 

The secret for getting pregnant by IVF is to be patient

Everyone knows that the cumulative IVF pregnancy rate increases with the number of IVF cycles you do .

This is true in the bedroom as well ! Even if fertile healthy young couples had sex daily, only about 25% would get pregnant in the first month; about  40% after 2 months;  60% would take about 6 months ; and 90% would take about a year to conceive, in spite of the fact that the eggs and sperm are perfect.

This is a biological fact of life, and is simply because human reproduction is not efficient .

Now fertile couples don’t mind being patient, because having baby making sex is free and fun.

However, when you need to do IVF to get pregnant, this changes matters considerably, because IVF cycles can be stressful and they are expensive !

This is why you need to select a clinic which transfers only top quality blastocysts, and transfers them only one at a time. The extra embryos are frozen, and reserved for future transfers. Thus, is you have 4 top quality blatocysts, the doctor can do 4 transfer cycles for you, rather than blindly bung them all in at one time,

The pregnancy rate over 4 cycles would obviously be much higher as compared to dumping them all in at one time.

And if you get pregnant in any of these cycles, you can preserve your frozen embryos for your next baby !

This is a simple option , which doesn't increase your costs too much, because transferring frozen embryos is much cheaper and easier than starting a fresh cycle,.

You can considerably improve your chances of getting pregnant , if you are willing to be patient , and have realistic expectations . This is why you need to find a good doctor, who understands the importance of maximizing your chances of getting pregnant ,without taking the risk of your having a multiple pregnancy

Why all IVF patients need to learn Meditation

There is no doubt that IVF can be an extremely stressful experience , and all the suspense , waiting and uncertainty can drive you crazy , because you can never be sure whether the cycle is going to work or not.

When the cycle fails, you don’t know what you need to change in order to achieve success, so both you and your doctor are often groping in the dark.

The treatment is expensive and intrusive , and can eat up a lot of your peace of mind .

The problem with infertility is it never just a personal medical problem. It has social and emotional overtones, and starts affecting your relationships with many people , as a result of which the quest for a baby starts consuming you , and your dream to get pregnant starts becoming an obsession.

 It’s normal to grapple for answers , and to look for certainty , but reality is that this just doesn't exist in the IVF process.

This can be both humbling and infuriating, because IVF failure is often the first time in their life that these young adults have had to deal with failure . It’s their first brush with their own mortality , because they realise that not everything is in their control , and just that being wealthy and throwing a lot of money at the problem, or going to the best doctor , doesn't mean that your problem will get solved.

This can be scary , and can cause both nightmares and sleepless nights.

While the final outcome will never be in our control, one simple free tool which can help is meditation. Learning to be mindfully aware can be very helpful , because it allows you to step outside your own skin, and appreciate that suffering is universal .

You can actually use this journey it to transmute yourself , and become a better person . You know that what doesn't kill you makes you stronger , and many infertile couples end up becoming better people , irrespective of whether they get a baby or not , because when they suffer themselves , they learn to be the more empathetic , and they can appreciate someone else's pain better .

Yes, it can be a difficult ride , but when life gives you lemons , sometimes all you can do is drink the lemonade rather than continue feeling sorry for yourself , because that really doesn't help anyone at all, and just makes a bad situation even worse

 

Why is your IVF doctor hiding information from you ?

 In an ideal world , every IVF doctor would treat the patient with respect , and make sure that they had realistic expectations of IVF treatment . At the time of the consultation, they would review the diagnosis with them , and prepare a treatment plan . They would explain what they were planning to do , how much time this would take, and what the costs and risks would be. This would ensure that patients are prepared for what was going to happen , because IVF treatment takes time, money and energy, and patients need to organise their finances, leaves and work commitments. That’s why it's important that they have realistic expectations as to how much time , energy and money they will have to invest in the process . IVF is elective treatment, and this is something which is very easy for every clinic to do .

The doctor should also explain why they've chosen a particular treatment plan , and what they will do to monitor the cycle to make sure everything is going well ; how they will be able to identity in case things don't go well ; what the checkpoints will be; and how they can correct for this, so patients know exactly what is going to happen and when . Patients hate unexpected surprises , and this openness and transparency is in the doctor's best interest , because it creates trust in the patient . Because the patient knows what is going to happen, they feel they are in control , rather than feeling helpless , lost and confused.

More importantly , when patients know what is planned, the chances for error go down dramatically , because patients become active participants in their treatment.

Sadly, most IVF clinics don’t bother to do any of this .

They modify treatment on the fly, and everything is very disorganised and unsystematic. They don’t share information with the patient, who often has no idea as to what is going on.

They don't provide a treatment plan , and it seems the treatment plan changes all the time, depending on who the doctor on duty happens to be . It often seems like the left hand doesn't know what the right hand is doing , and the poor patient is clueless and lost. Are things going the way they were supposed to ? Is the response good ? or bad ?

They only find out there is a problem when the cycle fails, when the doctor reviews the records with the patient, and it comes up with all kinds of excuses , pretexts and reasons for why the cycle failed.

The poor patient feels cheated , and wants to know why this information wasn’t shared proactively, before the cycle was started. They want to know – Why are telling me this at the last minute ? – but don’t have the guts to express their displeasure.

 My advice is simple – learn to be proactive and assertive , because you are the one who will be spending a lot of money on your treatment. Ask for all this information upfront – this is your right, and you don’t need to be aggressive. The doctor is not doing you a favour by providing this - you have paid for his services  and have a right to know

If the doctor is rude, and refuses to answer your questions and treat you with respect , then you are definitely in the wrong IVF clinic .

You need to find a better doctor , who will treat you like a respected intelligent adult