Patients with poor ovarian reserve can be extremely hard to counsel, especially when they're young and have regular periods because they can't understand why they're not being able to get pregnant and why they're failing repeated IVF cycles. After all, they have eggs, they're growing embryos, lots of other women are getting pregnant, even women who are much older than them. Why aren't they being able to manage?
I think it's important they understand that just because they're making embryos doesn't mean that these embryos are good quality enough to be able to implant. This is a problem especially, for example, when they do a day 2 or a day 3 transfer and they have a good 8-cell embryo and they think, "Great. Since my uterus is normal and the doctor has managed to make the embryo for me, I should get pregnant." Unfortunately, if you have poor quality eggs, you end up with poor quality embryos which don't implant.
Of course, the big problem is you can't make out looking at an embryo whether it's good quality or not. This is true whether it's a day 3 transfer or a day 5 transfer. After all, we know that even perfect embryos will have genetic abnormalities which will prevent them from implanting. We don't have the ability to test these because PGD only allows us to check for chromosomal abnormalities and not genetic abnormalities. Older eggs, because they're older or because they come from ovaries which have aged, as reflected by poor ovarian reserve, will often accumulate a lot of these genetic abnormalities as a result of which these embryos are destined never to implant.
There's no way we can prove this, so that makes it even more frustrating for the patient. We get a good quality embryo, of course the patient is excited and so is the doctor because these are challenging patients, hard to work with. Being able to make an embryo for them is very gratifying, but we forget that patients don't just want good quality embryos. They need a baby.
One solution, of course, is to grow these embryos to day 5 and not transfer on day 2 or 3. Now, it's very tempting to put them back on day 3, especially when there are such few eggs because each of these embryos is worth its weight in gold, but my point is that if it's going to arrest, then it's better that it does that at the lab, so at least we have useful information we can assimilate and utilize when making treatment plans for the next cycle in case this cycle fails. What happens if the embryo does arrest? So be it. If it's going to arrest in the lab, it would have arrested in the uterus as well and would never have become a baby. If it is going to become a baby in the uterus, then it will definitely form a blastocyst in the lab as well. Of course, you need a very good lab and a very confident doctor, but this is the best approach.
Just because you make a good quality blastocyst, and even if you do PGS and that PGS is normal, that doesn't mean that embryo is going to become a baby, as I've already explained. You need to accept the fact that some of these things are beyond our control. You need to be prepared for failure so that you don't go to pieces and you're able to move on and think of alternative options rather than get paralyzed.
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