The bane of overtesting after a failed IVF cycle
More is not always better - and too many tests can create more problems then they solve !
I just saw a patient who had failed an IVF cycle. She was full of questions and was very confused because her doctor could not provide her with satisfactory answers. Her doctor had transferred two good quality blastocysts but these had failed to implant , and she wanted to know why. At the time of the transfer, the doctor was extremely optimistic and gung-ho - and had virtually promised her that she was going to get pregnant in this cycle, because everything was going so well ! When the cycle failed, the patient was distraught, and confronted her doctor, asking her for an explanation as to the failure.
The doctor then did what all doctors tend to do - ask for more tests ! She ran a panel of very expensive tests, including a sperm DNA fragmentation index - and this test result came back as abnormal . The doctor pointed out this abnormality, and told her that this was the reason why her cycle had failed ! She proposed that in the next attempt , they do a TESA or use donor sperm. The patient was completely nonplussed , because none of this made any sense to her.
The first doubt which popped up in her mind was that if this was such an important test , then why hadn't the doctor asked her to do the test before starting the IVF cycle, rather than afterwards ? She was a computer engineer, and felt the doctor was being logically inconsistent , which is why her BS detector was on full alert , and she wanted a second opinion from me.
I see this problem all the time. Unfortunately , most patients are not adequately prepared for the fact that most IVF cycles fail. Doctors are happy to paint an excessively rosy picture before starting the cycle, in order to persuade patients to sign up - and when the cycle fails, patients are forced to confront the reality that we still do not know why embryos do not become babies ! This is true , whether we are doing IVF in the clinic , or fertile patients are having intercourse in the bedroom . Human reproduction remains an inefficient enterprise , whether it's in vitro or in vivo.
The honest answer for most IVF failures, when we transfer good-quality embryos into a good-looking endometrium is that we do not know why the embryos did not implant. However, if doctors are upfront with their patients and tell them the truth, many patients get upset because they feel that this means their doctor is ignorant and not very well informed. Because doctors are scared that if they tell the patient a truthful " I do not know ", the patient may leave them and go to another doctor , they will often manufacture reasons to placate the patient. Some of these reasons are completely ridiculous - " You did not rest after your embryo transfer, which is why your embryos fell out". Others are more sophisticated and are based on running a panel of expensive tests , such as sperm DNA fragmentation and NK cells, but the fact remains that these " reasons " are equally dishonest.
The only solution to this problem is to counsel patients before the cycle starts . We need to explain exactly what the limitations of our technology are, so that even if the cycle fails , the patient does not go to pieces , because she's been prepared for this, and can take it in her stride , even if she is emotionally distraught . A well prepared patient does not pressurize the doctor into manufacturing pseudo-answers, just to keep her happy !