An IVF cycle failed. We are so sorry, but, from the failure can come great knowledge and a chance to improve your chances of having a baby. You need to sit with the doctor and review.
Doctor? What doctor? Have you seen the doctor?
Here is what we do at Fertility Partnership.
Welcome to the Fertility Partnership. I am Dr Simckes and I am proud that the CDC recently released data that placed Fertility Partnership as #2 in Missouri for Live Birth success rates (35-37). Our most recent data to be released in the spring is even better. At FP we fight the battle to bring down IVF costs and have proven that it does not effect success rates. Based on these results, perhaps less financial stress actually improves outcomes.
If you have been through an IVF cycle and did not succeed you need to pause and review what happened. Whether you had a negative pregnancy test, a chemical pregnancy, or even a later loss, you need to look at all the factors before you move on. No program can guarantee you success and any program that does should be viewed with suspicion. Nevertheless, every failed cycle should be reviewed to look for what went right and what went wrong so as to improve the outcome. Unfortunately, very few doctors sit down after failed cycle review each step. At FP, it is the standard of care. It can be uncomfortable for a doctor to face a couple who have been unsuccessful and perhaps that is why so few do it. A failed cycle is valuable because it can teach us what we need to change. Sometimes it is just good to sit down and have closure.
So where to begin? Well, you need to break it down. I like to think stepwise:
- Egg number and quality – The stimulation
- Fertilization and embryo development – What happened in the Lab
- The transfer of embryos
- Uterine and other maternal factors that may have prevented implantation
First you have to look at the stimulation. The primary goal for the clinical team is to figure out how to get the optimal number of M2 oocytes (mature eggs) through the lab window in the operating room. We do not want to overstimulate the ovaries because that opens up another set of problems. So after a failed cycle I like to review the number of M2’s that were handed over to the lab, and the ratio of M2s to the other “non-mature” eggs. That lets us know if we stimulated with the appropriate amount of medication, the right number of days, and the effect of the “triggering medication” on the follicles. There can be a wide variation as to what is normal but anything off the bell-curve may unmask an underlying egg issue. Sometimes the eggs just don’t look good. They can be darker than expected or their outer wall is soft and mushy when the sperm is introduced. This may imply that the stimulation lasted too long.
Next we want to look at how the eggs fertilized and the quality of the embryos that were made. So many factors can influence this. Egg quality is crucial but the quality of the sperm can also be a factor here. Did the embryos divide well and in a timely fashion? Did they fragment as the cells divided? The embryos get “graded” on day 3 and day 5 of their development so at our Review Meeting we review the “report card” that the lab provides. I like to actually show the report to the couple so they can see how their embryos developed. I think the transparency is reassuring and also can help support my recommendations.
If we had good embryos, was there difficulty during the transfer of the embryos into the womb? As a patient you usually can tell if there was a struggle to place the embryos. Did the transfer go smoothly? Did it take more than ten or fifteen minutes? Maybe the doctor struggled trying to navigate his way through your cervix to get to the uterine cavity. Clues to this can be found in the report from the lab when they typically let the doctor know if there was blood or mucus in the catheter when it was returned for inspection after the transfer. The catheter gets inspected to ensure that the embryos are out and in the womb. Sometimes I am surprised as there is blood in the catheter despite the transfer being as smooth as silk. A bloody transfer can lower the odds of success and can potentially be avoided in the future. It is also important to know that occasionally an embryo actually gets retained or stuck in the catheter and the team has to reload it and transfer again. Transferring twice may also lower your success rate.
Next I ask why, if good embryos were safely placed into the uterine cavity, why did they not implant and continue to grow? Any and all uterine factors need to be addressed and treated if possible. Was the endometrial lining thick enough? Most agree it should be between 6-14mm (I prefer 8-12mm). Were there other uterine factors such as fibroids or a polyp? A hysteroscopy may need to be performed. A fibroid may need to be removed. Are the fallopian tubes blocked and dilated? If so they may need to be removed before the next transfer. Is there a history of prior pregnancy losses that has not been addressed? Perhaps there are factors in the woman’s blood that could be preventing good implantation and development. Blood work for “recurrent pregnancy loss” may need to be drawn and appropriate medications given to try to prevent a recurrence.
After reviewing the stimulation, quality of the eggs, quality of the embryos, the ease of the transfer, you are often left with no answers as to why they didn’t implant. A doctor will remind you that the odds are never 100% and so the best you can do is try again. Perhaps you had a chemical pregnancy and then the doctor will say that it is likely that they were just not genetically normal and try again. The recommendations are generally to encourage couples to try at least three times before throwing in the towel. Many just simply cannot afford that many attempts and want to optimize their chances as soon as possible.
After all the various factors have been optimized what else can you do it increase the likelihood that the next time will work?
Let’s focus on the issue of choosing the right embryos. As I wrote earlier the embryos are graded and we tend to put in the best looking embryos with the assumption that if they look better they are better. The reality is that how the embryo looks is no guarantee of the embryo’s competency and often it is the ugly duckling on Day 3 of growth that becomes the swan on Day 5. In the end it is not really a beauty contest; it is about the genetics, or karyotype, of the embryo.
Unfortunately many patients aren’t lucky enough to have enough embryos to actually choose from but for those who do, there are technological advances that can help you. In the last few years the placing cameras in the incubators and watching the embryos divide and grow using time lapse photography has become commercially available. The concept is that if the embryos divide appropriately and in a timely fashion they are more likely to be genetically normal and, if chosen, will increase your chance of a live birth baby. The technology is not low-priced and I am not sure at this time if the current scientific studies and reviews prove that the technology is worth the expense. I personally have entertained purchasing one of these systems but have held back because I believe there is not enough evidence to justify cost and we have found a better solution. The embryo cameras and scopes may help you guess at which embryo is normal but how would it be if you actually knew which are normal. This is accomplished by biopsying the embryo on day 5 and removing a few cells. This, process is called Pre-implantation Genetic Screening-PGS. The cells are then tested to see their chromosomes, 46XX for a girl, 46XY for a boy. Most clinics, including our own Fertility Partnership, report that if we transfer 1 or 2 Day 5 biopsy proven, genetically normal, embryos the pregnancy rate is in the 70%-80% or higher. Even better is that because the transferred embryos are genetically normal the miscarriage rate drops dramatically- although it is still not zero. Clinics, like ours, that do PGS have ongoing pregnancies and live birth rates in the 60%-70% range.
I want to wish you the best of luck on your journey. There are many unanswered questions in the field of infertility. The technology is always changing. Never stop asking questions. I know we don’t.