This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.
The first question that arises in a patient's mind after an IVF failure is 'Why did my cycle fail ?' A failed IVF cycle is heart-wrenching. It is painful because your dreams are shattered, your hard-earned money has gone down the tube and you do not know what to do next ! As humans we all need an answer for the failures we encounter. Why did a particular endeavor fail ? If we get an answer for this , then we tend to have peace of mind , because we believe that we can achieve success the next time around if we can rectify what went wrong in the previous attempt. But when an IVF cycle fails unfortunately no one has an answer for the same - not even your doctor ! You might have had a perfect cycle - lots of eggs, good fertilization rate, good quality embryos, excellent endometrium, easy embryo transfer - but no positive pregnancy test !
On the other hand your friend might have had a very poor IVF cycle (with few eggs and poor quality embryos) and they might end up getting pregnant ! IVF is like a gamble - which involves not only your money , but also your fragile baby dreams ! The sad truth is that there is no logical explanation for the outcome of an IVF cycle - be it a success or a failure. This is because we are still not intelligent enough to understand the logic beyond the bio'logical' process that controls embryo development and implantation. Once the embryo is transferred to the uterus , no one knows what happens to it after this- after all, how can we track the fate of a microscopic ball of cells once they are inside the uterine cavity ? We cannot predict which embryos will implant and why, and hence we do not know why an IVF cycle fails or succeeds ! Fortunately or unfortunately , no one cares the other logical question - 'Why did my cycle succeed ?' - this doesn't have an answer either !
The first person patients turn to when their IVF cycle fails is their doctor. He is the person who performed everything from the ovarian stimulation to the embryo transfer. He is the one who advised them to do IVF ; and reassured them that they had a good chance of succeeding. Patients naturally think that their doctor should have an answer for the most important question that haunts them - 'Why did my cycle fail ?' There are patients who are naive about the IVF process , and who get angry with their doctor when he cannot offer a satisfactory answer for the failure. They start imagining the worst - that their doctor did not perform the procedure well, or that the clinic is not competent , which is why the cycle failed. Some might blame themselves , because they start thinking that their body is not conducive for achieving a pregnancy; that their uterus is not good enough to accept the embryo; and that they are not fit to carry a baby. Some believe that their body is defective or that it "rejected" the embryo. Many start obsessing about all the 'mistakes' they did during the 2ww - from not taking enough rest to eating certain 'forbidden' foods. Many patients start blaming themselves for the IVF failure and might even think that it is a punishment from God ! But a well-informed, IVF literate patient understands that an IVF failure is nobody's fault. Such mature patients get better emotional protection after an IVF failure because they do not blame others or themselves for the failure. They do not think their body is defective (and hence their self-esteem is not damaged) ; and they accept the failure with a strong heart and mind which will in turn help them to look forward for ways to make their baby dreams come true !
The most important duty of an IVF doctor is to teach his patients how to prepare themselves for an IVF failure. A good IVF specialist will spend time and energy to educate his patients about the uncertainty inherent in an IVF process. He will not falsely raise the hopes of his patients and he will not promise them a baby. Such a mature doctor not only protects his patients from the emotional assault of failure, but also protects himself from the wrath of his patients ; and also does not need to trot out a plausible lie to satisfy the patient when the cycle fails !
What causes an IVF cycle to fail ?
No one knows the answer ! There are some explanations , for example - poor quality of the embryo ; genetic defects in the embryos ( which we cannot always diagnose); or the presence of an unreceptive endometrium. But the problem with existing IVF technology is that there are no sure ways to find out which embryo is genetically normal and which endometrium is receptive. Hence giving an exact reason for the IVF failure to an individual patient is not always feasible , because of the limitations inherent in today's ART. Let us consider a fertile couple who is trying to have a baby in their bedroom. Do their attempts at baby making sex result in a baby every month they have intercourse during their fertile time ? Of course not ! A young fertile couple may take up to one year to achieve a pregnancy - and they have just a 15 - 25 % chance of conceiving in a particular menstrual cycle. This clearly shows that human reproduction is remarkably inefficient. During IVF the chance of achieving a pregnancy in a single attempt is significantly higher- most clinics around the world have a success rate of 40-50 %. But it is impossible to pinpoint why 6 out of 10 women who undergo IVF fail to achieve a pregnancy and why the other 4 are successful in their attempt.
What will not cause your IVF cycle to fail ?
The following will not cause your IVF cycle to fail :
- Not taking bed rest
- Your food habits (eating the so called 'heat generating' foods ! ( for example chicken etc)
- Pseudoscientific reasons such as NK cells and HLA matching
Patients don't like being told doctors don't have all the answers ! This makes them uncomfortable, and they start doubting their doctor's competence. If he cannot even answer such a basic question, then he must not be very good ? Maybe we need to get a second opinion ? This is especially true when the doctor overpromises success before starting the IVF cycle ( as many do, to lure the patients into doing IVF with them). They promise them the earth and the moon - and when they cycle fails, they often abandon these patients and refuse to see them, as they don't want to have to answer awkward questions. Even worse, rather than acknowledge the state of our ignorance, other doctors will concoct pseudo-scientific answers for the failure, such as immune rejection because of overactive NK cells in the uterus ; or HLA similarity between the partners. They will then run a panel of expensive and painful tests ( of no proven validity) , and then find "abnormalities" which they will then go on to "treat" before starting the next IVF cycle. The patient is hooked, because she believes that the doctor has now pinpointed the fault - and now that it has been corrected, the next IVF cycle will definitely succeed ! Many are sadly disillusioned when the next cycle also fails - and they then start belatedly doing their homework !
What happens when an IVF cycle fails ?
Even though the patient tries to understand that there is no valid explanation for an IVF failure , many a time the heart is not ready to accept what the head says. As it is rightly said , the heart has reasons that reason does not understand.Since there are so many emotions connected with an IVF cycle , the heart of a patient naturally craves for an explanation for the failure , so that the " fault " can be rectified in the subsequent
cycle . They believe that this will help in achieving the much desired pregnancy. This is where many IVF doctors play games with their patients - some for money, some unable to face patient's questions, some because of the fear that they might lose the patient to other doctor and some in order to maintain their 'I know everything' image !
How do IVF doctors react when their patients demand an explanation for the failure ?
When an immature IVF doctor is confronted with the question - 'why did my cycle fail ?' he may feel offended. Many feel that their clinic's competency is being questioned ! Many doctors will accuse the patients for the IVF failure. They might say : your uterus is not good enough; you didn't take enough bed rest; you did not follow my orders etc. Such answers will increase the patient's agony because they start believing that they are the reason for the failed IVF.
There are doctors who have a very paternalistic approach. They feel they are like God and no one should question them. They take pride in their intelligence and in their ability to give answers to all the patient's questions. When such doctors are confronted with the 'why did my cycle fail ?' question , they order a list of expensive, useless tests and subject the patients to treatments which have never been proven to be helpful. Ironically , this gives immense satisfaction to patients , because they believe their doctor is striving hard to find where the fault is ; and will be able to rectify it with expensive treatments. Patients delude themselves that costly treatments are highly effective and the doctor in turn gets the satisfaction that he has given appropriate answers to the patient's question ( because many of these test results turn out to be abnormal, even though the abnormality is of no clinical importance).
Only a mature doctor has the courage to give the honest answer - 'I do not know' !Of course , there are patients who are not mature enough to accept this explanation , nor do they appreciate the doctor's honesty. They think that the doctor is not knowledgeable enough to guide them and look for doctors who will give them an explanation for their IVF failure. They believe that since that particular doctor has an explanation for the failure , he will make sure that the pitfall is corrected and make their next IVF cycle a success !
What are some of the futile treatments employed in the field of IVF ?
The below treatments do not have any scientific proof for their efficiency !
- IVIG therapy - Intravenous immunoglobulin therapy
- Intralipid therapy
- Paternal lymphocyte immunotherapy
- Use of heparin
Try again ! This is the only good answer and a good IVF doctor's answer will be exactly this. Of course, he may make changes, based on your response, and he will explain these to you. A good doctor will not order a bunch of expensive tests after each IVF failure and doctor will make sure that his patients have realistic expectation about the entire IVF process. If you want to be a mature IVF patient , educate yourself about the process. This will help you to have sensible expectations of IVF treatment. It will protect you from an emotional breakdown ; and from unnecessary tests and treatments.
If IVF treatment is like a gamble, are there ways to reap the best out of what I pay ?
There are clinics which want to make the IVF treatment a win-win situation. They offer something called a money back guarantee programme. You pay for a certain number of cycles (for example 3 IVF cycles) and if you do not get pregnant within those 3 cycles , they give you back your money. This is a wonderful option , which could help you preserve your peace of mind , at least as regards the financial aspect. So before starting an IVF cycle make sure that your clinic has such an option and ask them whether you qualify for such a programme.
The field of IVF is highly commercial and you need to protect yourself from being exploited by money-minded and irrational physicians. Your doctor is not always correct and unbiased. So please become well-informed about the process before starting it. Find a good doctor who will have your best interests at heart. If you are constantly diverted from your aim of having a baby by having to do unnecessary tests and treatments , you will get exhausted very soon. It makes going through subsequent IVFs impossible. Being knowledgeable and having realistic expectations about IVF will help you to remain strong , and will keep you going. Be careful not to get fed up before getting pregnant !
Her blog is at www.myselfishgenes.blogspot.com