This is the third in a series of responses to common questions about Failed IVF Treatment.

Question #3 - Who is to Blame for My IVF Failure?

Couples undergoing IVF inherently realize that IVF treatment does not guarantee a successful outcome. Yet, in spite of this reality, the vast majority of patients are so charged when IVF treatment fails, they feel extremely let-down, disappointed, sad, or even angry and resentful. Many will direct this anger and resentment at the medical caregivers. After all, these were the very people in whom they entrusted their dreams…They must have “goofed up” somewhere along the line.

It is an unfortunate reality that even the very best infertility treatment does not guarantee an optimal outcome. Nowhere is this truer than in the field of Reproductive Medicine. The fact is that regardless of expertise, intent, the best quality of care, and access to superior technology, at least one in two IVF treatments will fail to result in the birth of a baby.

Dealing with patients who get “the bad news” of a failed IVF cycle is the most common and also the most challenging situation that IVF doctors must confront on a regular basis. It often puts the treating doctor on the defensive. It can be so traumatic that some fertility physicians try to avoid the confrontation by making themselves unavailable for questions, and in some cases, avoiding the issue altogether by having someone else (often a nurse) deal with it. This is a big mistake!

It is impossible to totally prevent the emotional trauma associated with IVF failure. The combined impact of emotional, physical and financial components makes this impossible. However there is a lot that a physician can do to limit patient distress:

Physicians should prepare their patients for the possibility of IVF failure well in advance: Since failure is a regular and inevitable part of IVF treatment, patients should be counseled well in advance of treatment on the real possibility that they might not be successful. Patients need to be counseled on the fact that while it is important to anticipate and hope for success, they should at the same time always prepare for the eventuality of failure. Nothing is more important in this regard than to help patients establishing rational expectations.To this end, the physician should:

• Never over-promise a successful outcome

• Carefully discuss those factors that affect outcome: a) cause of infertility;b) age of the woman; c) effect of ovarian reserve; d) quality of the sperm; e) uterine factors; f) the possible influence of immunologic factors and, g) the number of prior IVF failures.

• Discuss the realistic chance of success: Because of the impossibility of assuring successful IVF in a single attempt, I personally try to focus on the cumulative chance of success over a few attempts. Here, I often use the concept of what the ultimate outcome might be if 100 patients with similar demographic and clinical circumstances were to commit to undergoing up to three attempts at IVF with me. This, by immediately establishing that it often takes more than one attempt to have an optimal chance of success, can avoid a potentially volatile encounter should treatment fail. The worst thing one can do is to create unrealistic expectations by over-promising, only to end up under-performing in the eyes of the patient.

• Establish a good line of communication: It is important to assure IVF patients that they at all times will have ready access to members of the medical team. At SIRM, we do this by providing each woman with a detailed calendar, and with email addresses as well as contact telephone numbers of key staff members. I readily provide my IVF patients with my personal cell phone number so that they can reach me on any urgent matter that might arise.

• Always meet expectations and fulfill all promises made: Nothing could be worse than promising patients ready access to information and staff members (including the doctor) and then failing to deliver.

• Provide patients with regular progress reports: Patients need to be meticulously updated on their progress throughout ultrasound and estradiol monitoring (on the status of their follicle count and growth), after egg retrieval (on egg quality and quantity), on the day post-fertilization (on the fertilization rate) and, on day 3 or on days 5/ 6 (on the number of left-over embryos that are eligible to be cryopreserved).

• Schedule post-pregnancy diagnosis consultations (in-person or by phone): The first such consultation should take place as soon as the 2^nd beta hCG pregnancy test results have been relayed. If negative, the physician should address the possible reasons for failure, recommendations for future testing, adjustments in protocol and timing for the next attempt (if applicable). Patients should be afforded the opportunity to have another follow-up consultation to define future strategy.

If the patient has appropriately rising hCG levels after treatment, another doctor’s consultation should be set for 2 -3 weeks later after the ultrasound examination to diagnose a clinical pregnancy. At all times, patients should be advised to call in the event of any intercurrent bleeding, cramping, pernicious vomiting or other perceived irregularities.

Some patients blame themselves for an IVF failure. In such cases they should be reassured that it is highly unlikely that anything they did or might have done (prior to, during or immediately after IVF) would have altered the final outcome. Husbands sometimes feel guilty of not having been supportive enough and perhaps of not having given the injections correctly. This too is usually unwarranted and they should be so informed.Finally, it is important to point out that by learning from the prior cycle and adjusting future treatment, the following attempt might be more likely to succeed.

Infertility is a state of disempowerment. The most important task of a physician is to re-empower the patient. Here, information is one of the most important tools. Patients need to know, not only what is being proposed or done on their behalf, but also the reason(s) as to why. I provide my patients with abundant reading material which includes articles that I have written (on this blog or elsewhere) on relevant topics, as well as articles written by other SIRM and non-SIRM physicians. This having been said, there is no substitute for one-on one interaction with patients prior to, during and following the IVF experience.

So if your cycle fails, try to get as much information as possible from this failure (getting a medical treatment summary including photos of your embryos is critically important!), give yourself time to grieve, and then move on!