Thursday, February 24, 2022

Why do embryos fail to implant in an IVF cycle ?


One of the most frustrating areas in IVF today is that of failed implantation – both for doctors as well as patients.

As IVF doctors , we want all our patients to get pregnant in the first cycle itself, because when they get pregnant , they refer many more patients to us. However, when they cycle fails, they get depressed , and are unhappy and upset, and we need to provide them a shoulder to cry on , which isn't much fun .

However, the fact of the matter is that while our technology is great at making good quality blastocysts in the lab,  after we transfer the good quality embryo into a receptive endometrium, we have no control over whether that embryo is going to implant or not .

This inconvenient truth is not comforting , either for doctors or patients . As specialists, we would love to have more control over the treatment which we offer to our patients , because that would allow us to offer them a 100% success guarantee every time we did IVF for them. This would make our life so much easier , because then all we would have to do is to collect the money , and then handover the baby. Sadly, we're still a long way from reaching that holy grail.

Yes, our technology is progressively getting better , but we may never get there, because human reproduction is still very inefficient - and that's true whether we are making babies in the bedroom , or in the IVF lab .

As IVF doctors, if nothing else , we learn humility very quickly, because we realise it's impossible for us to be able to predict which embryo will become a baby , and which won’t.

The truth is that when an IVF cycle is successful, we don't know why it worked, though no one ever demands to know why it was successful ! We have to be cognizant of the fact that implantation is still a black box , and that no matter how hard we try , our technology still cannot reveal all the answers which Nature chooses to conceal from us .

The problem is that patients don't want to hear the truth , because they don’t want to confront the fact that doctors are ignorant. They are paying large amounts of money , and want a certain degree of certainty from the doctor. This is why they prefer doctors who will provide them with a degree of comfort by telling them what they want to hear , even if it’s not the truth.

This is why, when an IVF cycle fails, doctors offer them many additional options as to what they can do differently in the next cycle to increase the chances of implantation . The standard procedure is to tell the patient to do more tests - for example , PGS to check the chromosomes of the embryo , or an ERA test to assess endometrialreceptivity .

It seems quite logical to do these tests , because they sound very scientific, but while doing these tests is very profitable for the clinic , the dirty little secret is they don't actually increase success rates for the patient .

This is not something which doctor is willing to volunteer information about,  and this is not something which patients want to hear . In fact, patients are quite happy with the doctor who does everything possible , irrespective of whether what the doctor is doing has actually been proven to be useful or not, because they feel that the more the technology which is being utilized,  the better their chances of getting pregnant .

This is completely flawed reasoning , and in fact it can backfire , because additional information just increases confidence , because we have more data points , but actually the accuracy goes down , because a lot of this information is misleading , and we end up going down multiple rabbit holes and chasing expensive red herrings.

Good doctors will inform patients as to what the limitations of the technology are , so they realistic expectations of the treatment, and understand what's in our control , and what's not .

Over time, the chances of getting pregnant with more cycles improves because the cumulative conception rate rises with the number of cycles you do , but there is never any certainty as to when it is going to work for any individual patient , and this is something both doctors and patients need to learn to live with.

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