The real success of a failed IVF cycle
The title came to my mind before I even woke up. Blame this to the fact that the day before a patient had told me that the result of her IVF cycle was negative. This negative result got “tied” together with another negative result, some days ago. Not that I did not know the difficulties of these cases to achieve a pregnancy, especially in their first attempt ever… It’s just that some times you do not know if the next thing you decide to do as an infertility specialist will be enough. Will end in a positive result. There are undoubtedly some “international” statistics, by the most important Authorities in the science of Assisted Reproduction, and the World Health Organization regarding the chances a woman has to give birth to a child with any of the methods of Assisted Reproduction. Those statistics show the possibility of giving birth to a child by IVF (live birth rate per cycle started). These statistics, more or less, (using different sources) indicate these chances of success:
30-43% for women younger than 35 years old
25 to 36% for women aged 35 to 37 years old
15 to 27% for women 38 to 40 years old
6 to 18% for women 41-42 years old
<5% for women older than 42 years old
The lower success rates come from different European Human Reproduction Authorities ( such as HFEA etc), the higher success rates come from the United States (SART). Each one of us, the IVF specialists, that has “reached” the highest of these success rates must be thrilled.
For that reason, when I am surfing on the internet and I come across clinics, both in Greece and abroad, that, for example, are talking about how easily a couple conceived in their first IVF attempt with them while they had failed many times somewhere else, or how easily, again with their first attempt, with this new “XYZ” method a woman at 42 became pregnant, or many more examples like those…welll i get really angry. Not that it does not happen, and fortunately Thank God, it happens to many. And only I know the joy and relief I feel for every positive result I get. Particularly if this success came with the first IVF attempt…However, for each couple that easily achieved a pregnancy (the first, second or the third time – what really matters is the fact that the outcome was ultimately positive) there are as many, or many more couples that have suffered and still suffer, and perhaps are at this crucial point that there is not any more hope for a positive outcome. I also get very angry when the “keyword” and the measure of success is ONLY the “success rates” rather than “safety”. I strongly believe safety comes first. But that is taken for granted… ( you tell me … Okay then … Pass)
Before I proceed, I would like to give you some very basic information to further understand the possibilities and restrictions that exist in any attempt to achieve a pregnancy. Fecundity rather than fertility, is the probability to have a clinically proven pregnancy (sac / embryo / cardiac function) during the menstrual cycle in couples that pregnancy was not achieved in the previous menstrual cycle. In young couples, with a free medical history, trying to conceive naturally, this probability per cycle is approximately 20%, while a 45%, 65%, 85% of couples (relatively young I repeat) will achieve a pregnancy after 3, 6 and 12 cycles of trying, while a 15% of those couples will not. Infertility, as defined by the World Health Organization, is the inability to achieve a pregnancy after 12 months of frequent (2-3 times a week) unprotected sexual intercourse, a situation primarily relating to this 15% of couples mentioned above, that do not achieve a clinically viable pregnancy, after a year of trying. In these undeniable statistics I want to deepen a little more, and become even more specific by age (MFR: monthly fecundity rate):
MFR: ~25% at 25 years
MFR: ~15% at 30 years
MFR: ~10% at 35 years
MFR: ~5% at 40 years
MFR: ~1% at 45 years
So when these are the data and the limitations from Mother Nature, one can easily understand how difficult and unrealistic is for a woman in her 40s to have 60% chances of success in a single IVF cycle… Of course if this woman is lucky enough to become pregnant in her first attempt, that is 100% success right? I do wish things were so easy…
Without any objection, in vitro fertilization (IVF) is an important scientific discovery. It is the only choice for thousands of couples who wish to become parents and cannot in a natural way. However, the one and only truth is that IVF does not always work. It can take time and lots of effort. There are many couples out there who need to undergo more than one IVF cycles before they finally achieve their goal: a pregnancy and the birth of a healthy baby. IVF is an extremely stressful and a very expensive process. Although it is very difficult both for the couple and the doctor to accept a negative result, unfortunately it happens. And this is the only truth. So many years now in this field of Assisted Reproduction, I have met couples who come, have an IVF cycle, and if the result is negative they go. They go elsewhere, where they are promised better results, or results in their first attempt. It does not happen often, but it does happen. For each couple that “came and left” because they did not succeed with us the first time (despite the limitations and difficulties in their diagnosis) I can show you a couple who came and got pregnant in their first attempt with our team. But this does not mean that we are necessarily better than the previous ones. Not necessarily worse than the next. Simple (of course no simple really) this is the way things are. There are several reasons why an IVF cycle may fail.
The point is for all to understand (patients and doctors) why this happened. And here lies the real success of an IVF failure. To understand, correct, improve.
So, the most basic reasons why IVF fails are the following:
The age of the woman.
The quality of oocytes and / or embryos.
Ovarian response to thevstimulation protocol.
Problems during implantation / problems in the endometrium.
Lets go a bit deeper. And see how and what we can do to “claim” better results in the next cycle:
Age: As a woman gets older her chances to become pregnant are getting lower. Of course, in no case that means that IVF will not work for you. As you can see, IVF ensures higher success rates than the monthly reproductive potential of any woman (MFR). What you can do: accept, no matter how hard it is, the limitations set by your age. Even if all your tests come out perfectly normal (hopefully) you still need to accept the odds. In that way, you will not lose really valuable time or spend money here and there, to potentially unnecessary tests or treatments. Together with your doctor, you will try to design a more personalized treatment plan, perhaps more strict time-wise, focusing on your “good” data and the valuable knowledge that you have carefully gathered from a previous therapy. And one more thing (food for thought): studies have shown that older men needed a longer period of time to make a woman pregnant.
Quality of oocytes and / or embryos: poor quality in oocytes (due to age, PCOS, endometriosis, genetic factors etc) with almost mathematical precision leads to poor embryo quality, another important factor that leads to failure. Not that sperm, if this also has poor quality is not playing its role, but various studies have shown that except in a few cases, the poor quality of oocytes is to blame for the poor quality of embryos, in more than 75% of the cases. Several embryos, despite their seemingly good quality, have genetic or chromosomal abnormalities, that make them, for the strict criteria mother nature applies, non viable or inadequate for implantation. Furthermore, some embryos, while developing, do not have enough cells to survive, and, even before that stage, the oocyte may have been inappropriate for fertilization or it may have been abnormally fertilized. What you can do: if poor quality is genetically determined or there is a medical reason, you can not really do a lot of things about it. But that does not mean you should make things even worse by drinking alcohol, smoking and having a very poor in healthy nutrients diet. You should not in any way do things that impair the function of the ovaries and testes. Also, something else, very important. Always ask the IVF clinic to provide you the photographs of the embryos or even the oocytes of any IVF effort you undertake. It would be great help for any doctor to know or remember the data of a failed cycle. Sometimes I see pictures of blastocysts (day5 or day6 embryos with characteristic morphology) that only blastocysts they are not. These pictures really are of great value.
Protocol / ovarian response: Sometimes it happens that a woman’s ovaries do not have an adequate response to the drugs and the protocol that have been selected for an IVF cycle, in order to develop multiple follicles / eggs. If you already have a reduced number of eggs, which likely is the case if you are over 37 years old, or have elevated FSH levels and very low levels of AMH, maybe it is more difficult for your body to react to the drugs used in In Vitro Fertilization. Simple put, if a woman’s body during a stimulated cycle “works” well, “responds” to the drugs and produces an adequate (expected) number of eggs, then, it is very likely to have a positive result. If it does not, then the chances of IVF success are considered lower. What you can do: do not proceed to the next IVF cycle before you analyze all the data that may be responsible with your doctor. Do you need to use a different protocol next time? Or should you undertake more targeted hormone tests before taking hormones again? And how many? If taking hormones does not seem to work for you, would it be reasonable/ appropriate to do an IVF in a natural cycle without drugs? Also, was the last protocol used easily understood and carried out? Were mistakes made that the next time can be avoided? These are very important parameters to think about for the next time.
Implantation: Perhaps the most common reason behind an unsuccessful IVF. Ovaries have been successfully stimulated, high rates of normal fertilization have been obtained, good quality (even checked with preceded preimplantation diagnosis) embryos, nice endometrium in ultrasound….The treatment however fails… This raises the issue of implantation of the embryo. Which may have stopped growing without knowing exactly why it happened. Or, there are genetic and/or other reasons that nature chose to “stop” further development at this point. Some studies suggest that chromosome abnormalities can cause problems in the implantation of embryos in proportion as high as 50% of cases…or even more. Other reasons include polyps and / or other problems in the endometrium or the uterus that have not yet been investigated.
In the last World Congress of Controversies in Obstetrics, Gynecology and Infertility I attended in Paris few months ago, it was discussed whether or not to perform something more “intrusive”, such as hysteroscopy even in cases of normal hysterosalpingpgraphies. That is because, in a significant 10-20% of cases, there is a bad “something” in the endometrium that only hysteroscopy can probably diagnose. But again, many times, this “something” is not found, even if you also proceed to one step further and perform diagnostic laparoscopy, so the frustration is even bigger. What you can do: discuss again and again all the parameters with your doctor and see what you can improve next time.
These are the four most common reasons IVF fails. But even if you have a failed IVF attempt, this does not mean that you should give up trying to get pregnant. No way…And this is precisely the positive and optimistic message I want to share with you. Before a new effort, discuss with your doctor all the parameters, make a file with all the data and photos, and do not hesitate to ask for references and a summary of your effort, in case you want to change your doctor or clinic. Think if you are happy with your doctor, your clinic and the services you receive in total, before trying again. Do not change “so easily” though just because you did not succeed in your first attempt. Unless there are more important issues that lead you to this change. Also, be frank and “open” with your doctor about what he or she thinks may have gone wrong and if there is anything that you or your partner can do to help things go smoothly next time. This will be the real success of a failed IVF cycle. The most important thing is to stay positive and not give up, as long as age and your personal diagnosis of infertility allows it.
Wish you well,