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As an IVF expert , it gives me great pleasure to be able to help infertile couples to have a baby. I am often asked to give a second opinion on failed IVF cycles, where patients have taken treatment at other IVF clinics , but the cycle has failed.

On going through the records, I find the earlier doctor has failed to make the right diagnosis , as a result of which the treatment given was incorrect.

A great example of is patients who have occult ( hidden) PCO (Polycystic Ovarian ). Classically, the typical patient with Polycystic Ovarian Disease is obese , hirsute and has irregular cycles .

These are easy to diagnose.

However, there are many other patients with Polycystic Ovarian Disease who have what is called Lean PCOD . They have PCO, but the diagnosis is missed , because these patients are often skinny ; have regular periods, and don't have excessive hair .

The problem is that the eye only sees what the mind knows .

When doctors don't think of this diagnosis , it is very easy for them to miss it .

Typically, these patients have a high AMH level; an abnormal LH to FSH ratio ; large ovaries and increased ovarian stroma on the vaginal ultrasound scan .

Often doctors miss this finding, and it’s only when they start the IVF treatment and find the patient grows too many follicles , that they realize that this hyper-response is because the patient had occult PCOD.

The problem is that even though the patient grows a large number of eggs, the quality of eggs is poor, because the underlying hyperinsulinemia has not been corrected. The abnormal endocrine milieu can cause genetically abnormal eggs, which result in genetically abnormal embryos, which means either the IVF cycle fails , or these patients get pregnant , but end up with a missed abortion , because the endocrine abnormality was not properly treated before starting the IVF cycle .

The good news is this an easy problem to treat , once you make the right diagnosis .

These patients should be treated with metformin and myoinositol to normalise their endocrine profile before doing an IVF cycle . This will correct their hyper-response, which means the eggs will be of better quality, and this will maximize their chances of having a healthy baby.

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.
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