When an IVF cycle fails, the first question patients ask is "What went wrong?" 
And the second question is "What can we do differently the next time? Is there something new  we can try out , which will help us to increase the chances of getting pregnant?" 

Now this is a perfectly reasonable question , but if the cycle has gone perfectly, there's often no need to change anything in the next cycle. Often, all the patient needs to do is be patient, and try again. 

The critical moment of truth in an IVF cycle is at the time of the embryo transfer . It is at this moment - well before we know whether the cycle is going to succeed or not , that we can critically analyze the cycle , and make decisions as to what do in the next cycle, if this one fails. If the cycle went well, then we can counsel the patient that if she is unlucky and this cycle fails, we can repeat the same protocol the next time. However, if there were issues, we can let the patient know what we need to tweak the next time around, and why.

Sadly, most doctors discuss the treatment plan for the next cycle only after the HCG result comes back as negative. However, this is not correct, because we already have all the medical information we need to plan the next cycle at time of the transfer . It is at this time, when everything is fresh, that we can evaluate the 3 critical variables which an IVF cycle teaches us - the embryo quality; the endometrial thickness and texture ; and how easy the transfer was. After we've transferred the embryos , we really get no further useful information at all. If the cycle fails, there are no additional actionable insights we get as to why it failed, so why do we need to wait for the outcome before designing the plan for the next cycle? 

When the cycle fails, the patient is distraught, which is why there is a lot of pressure on both the patient and the doctor to do something new the next time. The reasoning is quite logical - after all, if the old cycle failed, and we continue doing the same thing the next time around, why should we expect a different outcome in the second cycle ?  However, the trick to IVF success is to be patient and to persevere, specially if the cycle was medically perfect.

This requires a lot of maturity , and it's not easy, especially when you've spent so much time, money and energy on the IVF cycle , and your hopes have come crashing down because it has failed. It can be very hard to deal with this emotional frustration , specially when the doctor said everything went well at the time of the transfer. Your expectations are extremely high , and you are sure that this time it's got to work . However, when it doesn't, it's hard to bounce back , which is why you should prepare a contingency plan at the time of the transfer itself.

The problem is that patients make a bad situation worse by demanding that their doctor do a lot of testing in order to answer their question as to what they can change for the next cycle. The hope is that if we introduce something new, we will be able to convert failure into success the next time around  . The doctor can see the patient is desperate, and in order to pacify her, is happy to order lots of additional tests and treatments, even though these have been shown not to be helpful. It's very tempting to do this - after all, what harm can doing more tests do ? The problem is that out of a sense of desperation , you end up being over tested and over treated. This wastes time and money, and doesn;t improve your chances of conceiving.

The truth is that a good IVF doctor will always do his best to get you pregnant in the first cycle itself. This is in everyone's best interests , because if you do get pregnant you are going to refer 10 other patients to us.  We are not going to conceal some special test or treatment, and use this selectively only when the first cycle fails. 

If we really had a treatment which would increase your chance of getting pregnant , then we would use it in the first cycle itself ! Why would we wait for your cycle to fail before offering this to you? 

I explain to patients that we are always going to do our best to get you pregnant. If the first cycle was a perfect cycle ( good blastocysts, good endometrium and an easy transfer), then there's no need to get disheartened. Sometimes you hit the jackpot the second time around - or sometimes it's third time lucky . I agree it's not easy to have to use words like luck when talking to a patient , because patients expect IVF experts to talk science , and to have all the answers . 

The problem is that these answers - such as "failed implantation" are just glib answers, full of medical jargon, which are actually designed to obfuscate matters . They only serve to conceal from patients how little we actually know about the process of implantation . Yes, it's easy to fool some of the patients  some of the time, but in the long run it's far better to be honest , and accept the fact that implantation is a black box over which we have no control . Once we transfer the embryo into the uterus, we are dependent on nature, and there is very little we can do to influence this process . Both doctors and patients need to learn to live with this uncertainty.

Can't understand what your doctor is saying ? Please email me and I'll be happy to help. This is my personal email id ( [email protected]) . You can also send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion and I will be happy to help you !


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

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