Q from U: When the IVF cycle fails; follow-up questions

April 13, 2012Carole 2 Comments »

Today I had this  question from a patient,  “How much info should you expect to get in terms of follow-up from your RE and lab after a failed cycle?”  She was expressing her frustration that all the follow-up she had was that they would try ICSI next time because she had zero percent fertilization in her IVF cycle. She was extremely frustrated that her doctor gave her no possible explanation or suggestions as to why there was zero fertilization in this cycle. She had a history of 5 previous IVF cycles with fertilization.

Her question is more difficult than it might seem at first. Every case is different. Sometimes there is no obvious reason or next steps. In her case, part of the problem was indeed communication. Specifically, that after multiple failed IVFs with diminishing returns, her physicians at two different clinics  never discussed the most obvious reason for her failed cycles. She was over 40 years old.

Now, I obviously wasn’t in the room so maybe they tried to tell her and she wasn’t ready to hear it. That would be  perfectly common and understandable human response. We have all been there. But if they simply never brought it up, I think they should be ashamed of themselves. Yes, there is obviously great risk with full disclosure, even if it is done diplomatically. Telling a woman that her age may be her biggest obstacle in achieving pregnancy is a message no patient wants to hear and she may well leave and never return. Many years ago, a doctor once said to me regarding a similar situation with another patient, “Well, if I don’t do the cycle someone else will. She will go ahead and do it somewhere else. Why shouldn’t I do it?” Why indeed. For me, turning away a patient seems a more ethical option than providing a service with little hope of success. Or worse, not fully disclosing all possible risks , benefits and ALTERNATIVES. That’s that pesky informed consent thing you hear mentioned (I imagine)  in medical school.

The American Society for Reproductive Medicine actually published an ethics committee opinion piece called ” Fertility treatment when the diagnosis is very poor or futile” that you can download from here.  They define “futile”  as less than 1% probability of a live birth and poor prognosis as between 1- 5% chance of a live birth. At 44, your chance of a live birth is under 3% and finally meets the ASRM ethics committee criteria for poor prognosis! Really? I would argue that you still should tell a 40 year old that all things being equal, her chance of a live birth is less than 20%–and if not futile- certainly a poor prognosis. How many of us would happily spend $12-20,000 out-of-pocket for a treatment that has a one-in-five chance of working? I think I’d want to know about that up front.

Here, copied from the ethics statement are the main points (bolded emphasis is mine):
1. For the purposes of this statement, ‘‘futility’’ refers to treatment that has a less than 1% chance of achieving a live birth;‘‘very poor prognosis’’ refers to treatment for which the odds of achieving a live birth are very low but not nonexistent(>1% to <5% per cycle).
2. Clinicians may refuse to initiate a treatment option they regard as futile or having a very poor prognosis. Referral information should be offered, if appropriate.
3. Decisions about treating or refusing to treat couples and/or individuals always should be patient-centered. Protecting fertility center success rates is not an ethical basis for refusing to treat couples and/or individuals with futile or very poor prognoses. Conversely, care should not be  provided solely for the financial benefit of the provider or center.
4. Upon request, clinicians may treat couples and/or individuals in cases of futility or very poor prognosis provided the clinician has assessed the risks and benefits and fully informed the couples and/or individuals of the low chance of success.
5. Thorough discussions are advisable at the beginning of the patient-physician interaction when couples and/or individuals have indicators of futility or very poor prognosis.
6. Fertility centers should develop evidence-based policies to guide decisions about treating couples and/or individuals with futile or very poor prognoses. In such cases the couples and/or individuals should be fully informed and offered information about referrals, especially if other clinics have had greater success with similar medical indications.
7. Decisions to refuse to initiate or continue infertility treatment should be made in cooperation with couples and/or individuals. Toward this end, it is advisable for clinicians periodically to revisit the treatment plan with couples and/or individuals.

Fertility and Sterility Vol. 92, No. 4, October 2009 0015-0282/09/$36.00

Assuming that your doctor has fully discussed the anticipated risks, benefits, alternatives and probability of success with you and the cycle still fails, what are some of the questions you can ask?

If fertilization is poor…what factors may have contributed to the poor outcome? Some factors could include egg maturity (related to stimulation protocol- what might we try different with the stimulation next time?) , sperm quality or quantity (are there medications or other factors that can be adjusted that might improve poor sperm quality?), lab factors (what is the normal fertilization rate you expect with conventional IVF?, with ICSI?

If embryo progression is poor and few if any embryos made it to transfer day with the expected cell number and low fragmentation rate, some questions you might ask include: What is your experience with embryo progression to day 3? to day 5? for patients like me? Are most of your transfers at day 3 or day 5? If day 3 transfers are the predominate type, that may be because the lab has had poor success with extended culture.

Ideally, these are questions you want to discuss up front. Do you do ICSI? How much ICSI do you do?- on all your patients? or a subset of patients if they meet criteria? What criteria do you use to decide whether ICSI is appropriate?

Unfortunately, sometimes there is no clear answer. Your team is as perplexed by an IVF failure as you are. They may not have all the answers but they should recognize that your questions are legitimate and should answer them thoughtfully and patiently. if they can’t or won’t, you can always find a more patient-centered clinic.

 

© 2012, Carole. All rights reserved.

2 Responses to this entry

  • It Is What It Is Says:

    Anyone who has been diagnosed with infertility and pursued ART in the hopes of having a child will tell you that even with full disclosure, when a woman hears “less than 20% chance of pregnancy (or live birth)” or “5% chance of success” what she thinks is, “why can’t that 5% be me? It means it has to work for someone”.

    The own egg cycle that produced my son when I was 40 had 10 embryos go to PGD. When my son was 6 months old and we began IVF again, I never approximated those results, not even close. Each cycle had diminishing returns: less follicles (even on higher doses of meds), less fertilized, less developed normally and still I persisted through another 5 OE IVFs (I did get have chemical pregnancies 3/5 times, so that fueled the fire). At that point, I was 41, had had success and it wasn’t until that last cycle when I think we had 4 or 5 embryos and a BFN, that I was finally able to process that there was a 90% chance of failure (or, in my case, seemingly 100%).

    In my eight years of treatments of all types and being as involved in both the on-line and IRL treatment of others, I have come to learn that every woman/couple’s process is different. Unless and until a couple hears ‘no chance of success’ it is very difficult for them to move on unless they’ve experienced whatever it is that they need to experience themselves.

    I wonder (and have been meaning to ask my RE and may at transfer tomorrow. YAY, all three embryos thawed!) if REs know that the IF community calls the post-cycle failure appointment a “WTF” appointment?

  • Carole Says:

    Hello It is what it is,
    I get it, I really do. Yours is the success story but –cue the statistics– not the common outcome. I sometimes felt in some programs that instead of working as a health partner, sharing information fully so patients could make good decisions for themselves, we instead catered to all levels of denial. If you wanted to know more, fine. If you wanted to know nothing, fine, the IVF line starts here and so on. It’s just so much simpler for everyone. Patients want and need hope. We have done “psychological cycles” for patients with almost zero chance but the doc felt it was necessary to go through another cycle to prove to the patient that further treatment was futile. We didn’t do these cycles for free. These cycles always bothered me because I thought it meant we had failed the educational mission. And was this ethical? I don’t know. The ethics committee said so but it still made me feel uncomfortable. There will always be someone to offer you more treatment. It’s harder to find someone who will discourage you from spending your last dollar. Good luck with your transfer!

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