April 13, 2020
Author Name: Dr. Mandar Vilas Gavate || Mentor Name: Dr. Reema on April 13, 2020
Infertility treatment can be a physically, emotionally and financially exhausting journey for a couple undergoing infertility treatment.
In our country, by the time a couple undergoes an ivf cycle, they have already spent years dealing with the social stigma of infertility. The treatment itself is demanding. One invests time, energy and money and it becomes the centre of their daily routine. Rest all the activities are put aside. Some even take a break from employment to completely focus on one goal that is a ‘healthy offspring’.
The process is even more demanding for the women – the investigations, the medicines, the procedures, daily injections can be very overwhelming for some; not just physically but emotionally as well. She is under a lot of pressure from the expectations of her family and friends [pregnancy – a sense of completeness].
And after going through all this, if the couple has a failed ivf cycle they are completely devastated.
To understand more about the causes behind a failed ivf cycle, let us first look at the factors which affect the success of the ivf treatment.
Most important is the age of the female partner, as with increasing age the number of eggs and their quality decreases and so does the quality and number of embryos formed. There is high chance of aneuploid embryos [chromosomally abnormal embryos] leading to higher chances of failed ivf.
Other important factor to be considered is the reason for which ivf was done. Studies show that ivf done for reasons like endometriosis and adenomyosis have more chances of failing as compared to ivf done for tubal problems or ovulation defects or male problems. All the comorbidities interfering with the success of treatment should be addressed by means of surgery [hystero-laparoscopy] or medications or special tests as warranted.
Couples who have had previous ivf failure as compared to a couple who is undergoing ivf for the first time will be assessed differently. Such couples may need to undergo extra investigations like karyotyping of both partners, looking for special genetic defects and may be given option for pre-conceptional genetic testing (PGT) of embryos also. A good 3D ultrasound is important to rule out structural abnormality of uterus.
This means the entire clinical picture will have to be considered before assessing the chances of success.
Another very important factor that plays a major role is the selection of the centre for undertaking fertility treatment. It is important to know how to select the Centre. Usually couples take two things into consideration while selecting the Centre for treatment:
• cost of treatment
• and distance of the Centre from their home
Though important, these two should actually be the secondary factors. Primary aim should be to select a Centre with Best results in terms of successful cycles which in turn is dependent on various other factors like:
•Availability of an experienced infertility specialist with good skills in handling the case. The doctor should be well versed with examinations, advising requisite investigations, performing ultrasonography [2d, 3d] so as to formulate and carry out an appropriate treatment protocol which will be suitable for the said couple .Remember, One size doesn’t fit all.
• Availability of well-equipped and State of the Art Embryology laboratory with latest technology like multiple good incubators, blastocyst culture, laser for assisted hatching, robust cryopreservation techniques for freeze- thaw cycles, prenatal genetic testing facility, are just to name a few.
• Availability of an in-house experienced embryologist who can run such a lab efficiently.
• Formulating and adhering to strict quality control measures and standard operating procedures forms the backbone of any good Centre.
To conclude, advancement in knowledge and technology has made achievement of higher success rates in ivf cycles possible. Nevertheless, ivf cycles do fail and more often than not, succeed in repeated attempts.
Let us now address the common questions that come to mind of the couple after a failed cycle. Also important is to understand the role of the treating doctor at this time. It is very common for the patient to think:
What went wrong?
It is important to deal with each question individually, because understanding and getting the answer to each question leads us to the other and helps us to come to an informed decision.
• Why me?
The couple waits for the day of result, preparing themselves, a bit anxious and tense at the same time, all the efforts culminating on this day. They are now informed that the result is negative [negative – beta HCG ]. This might come as a shock to many, now not willing to accept the result they ask the doctor to re-check. Some might be infuriated, angry and some accept the result humbly but are heartbroken. Denial and anger needs to be tackled well. It is the onus of the treating doctor to break the news empathetically. Inspite of all the efforts the doctor must be prepared to take on the aftermath of the result.
Challenges faced immediately – blame game.
The couple starts rewinding the whole treatment plan right from the day they stepped in to take treatment. The points of inconvenience, regarding staff behavior, billing, doctor’s incompetence and deficiency in facilities at the center. If that is not enough some couple do start blaming themselves –they ask if any activity of theirs has led to the negative result. Right from diet, forgetting medicines and not taking enough precaution. Some might also be depressed, there is a feeling of despair that they have reached a dead end.
How to overcome the immediate challenges – empathy
The doctor should be empathetic in the approach. Break the news of negative result very carefully, ensure both the husband and wife are present. Give time to the couple to understand and accept the result. Don’t start bombarding the patient with medical terminologies and don’t put forth next options as this time their minds will be least receptive to any new suggestions. Listen to what the couple needs to say, even if they try to blame you for the result.
Next help them to accept the result. Tell them it is not a dead end, there are many options open for them. Tell the couple that both parties have tried their best, but the outcome is never 100% inspite of the best of all situations. Ask the patient to come back after a break of one and a half month [six weeks], this allows them to overcome the grief. Also give them all possible support and keep your doors open if in between if they need help.
• Challenges faced intermediately – emotions and finances.
Some couples do experience depression, anxiety, some might just give up on the treatment in view of the emotional burden, some resume their work and are not able to resume treatment, some due to financial constraints, some feel it is not in their destiny to bear an offspring and just give up. Some have an already strained relationship which gets worse in this phase. It is very difficult time for the couples, in some situations relations end in a divorce.
How to overcome the intermediate challenges – Counselling and planning.
Role of the treating doctor – one should also act as a counsellor, ask the patient to follow up, tell them about the milestones achieved even during their failed ivf cycle; like couple taking treatment for first time lands in failure should be told the number of embryos formed, tell them if frozen embryos are there, they can be used next time. Also inform them that it is a known fact that couples with failed ivf cycle have got success after repeated ivf attempts too. This also is encouraging. They may even be encouraged to meet other couples at the centre who might have got previous failed cycle and now have an ongoing pregnancy. This will boost up their morale. Counselling and family support is very helpful at this time.
What went wrong?
Mostly couples after a break are able to overcome their grief and are out of denial, they understand that failed ivf once is not the end. Now when they have come to terms with reality, next question that comes to mind is what went wrong. Now is the time for the doctor to have a discussion with the couple regarding the probable reasons that led to failure.
In some cases at the beginning of the treatment itself, couples are informed of the poor prognosis in view of say increasing maternal age , diminished ovarian reserve , poor endometrium , poor sperm parameters ,etc. and are likewise advised to go for donor programs [egg / sperm / embryo] in view of their specific poor parameters so as to give best results. But they might not consider this thinking of having their own biological child in-spite of poor prognosis.
In some cases non-compliance to treatment can be detrimental to the outcome. Some do refuse special investigations like PGTA, Karyotyping, etc. Some even defer treatment options like platelet rich plasma to improve endometrium, hystero-laparoscopy for pathologies that might hinder treatment. This could be due to financial constraints. All these might lead to poor outcome and couples must be counselled well.
Once the couple have been explained well the possible factors which could have resulted in a poor outcome, next step is to plan their cycle. Couple should be emphasized the need to be complaint to the advises given to them. Explain the need for further investigations and interventions required to improve the result which they might have refused or skipped previously. Let them have an open discussion
Most important the couple should keep realistic expectations and realize ‘failed ivf is not the end – take detour’.
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