Dear Lord Robert Winston

I’m confused about how to proceed with my IVF clinic. I’m 38 almost 39. I have no fertility problems and am a good responder to drugs. I did IVF ICSI in 2011 and got pregnant 1st time with what they described as a very early day 5 blastocyst (low grade). The cycle produced 9 eggs, 6 mature and all 6 were fertilised but only 1 used. None were frozen but I have an amazing daughter. The clinical service was great and very informative at the time. Last year we did IVF ICSI again with the same clinic and had a very different experience. My response was still good -9 eggs again all mature all 9 fertilised, my husband’s sperm count increased 5 times to 20 million-ish. We had 9 embryos all doing well, got to day 5, had 3 excellent blastocysts. I wanted 2 put back but I was talked out of it! The cycle failed… We went on to put in our 2 frozen from the same cycle; sadly at the time of transfer both were unexpanded, one at 50% one at 70%. It was a living nightmare and the whole thing ended in failure. We still have to pay for the freezing of the embryos and the FET bit, its very expensive and we were confused as to why such a good crop of embryos totally failed especially after having a baby with what appeared as not as good an embryo. Unfortunately, we have had no real answers (maybe there are none) and we were also confused as to why they put back unexpanded embryos …? Is this a clinic we should go back to? We have been offered a dedicated doctor to look after us next time so we dont feel so batted about but I’m still concerned. Is it better to move on from a clinic when you have had failure with high quality embryos? The clinic have said they did everything correct medically and maybe we are looking for too many answers??..It’s such a huge amount of money and such a costly emotional process you just want to feel that you are getting the right advice and care at every level. We have far more contact with the finance department than with any doctor or nurse. I’m actually in a place were I don’t know if I could cope doing it all again. It would be great to have a bigger family but the last experience has left me very sad. Thank you for any advice. From S.

Reply….

 

Dear S,

I am sorry that you have this very distressing situation and feel both sad and at a loss about what to do next.

I think the key issue is the question of embryo quality. Of course, a poorly formed embryo is unlikely to produce a pregnancy though it may occasionally. But I think it is regrettable that embryologists and other staff in IVF clinics continue to give meaningless information to patients about the quality of the embryos they can see down the microscope when they look ‘good’. It is worth thinking about what they are actually looking at. They are looking at high magnification at a very imperfect image of a faintly outlined cell without being able to see any detail inside the cell at all. Most of the time it isn’t even possible to clearly identify the nucleus which is the control centre of every cell. Even if you can see the nucleus, you cannot see the DNA or all the other structures and molecules inside it. So an embryo may look perfectly formed, but this is a very imperfect impression of something which is incredibly complex. Think about it: this tiny object is going to be a complex organism like your beloved daughter with all the characteristics which make her development possible. So the judgement of whether this is a ‘good’ or a ‘bad’ embryo is actually nonsense. I often say that this is like looking at a person you don’t know on a tube train, and declaring he looks very intelligent. Alternatively, looking at somebody who you’ve never met before and saying he looks really stupid – but when you stop talking to him, you realise he is highly intelligent and very well-informed. It’s an old adage ‘ things are not always what they seem’ and it is certainly true of human embryos imperfectly magnified under a conventional microscope.

Now the next issue is this. On average, each embryo which looks ‘perfectly formed’ after in vitro fertilisation, has roughly speaking about a 20% chance of implanting and becoming a baby. It is true that a blastocyst has a slightly higher chance of implanting and becoming a baby around 30% or very slightly more. This is because most ‘good-looking’ embryos are simply not capable of developing into babies. Humans are unique in this respect. It seems that in most species, most perfectly formed embryos will implant. Humans however seem naturally infertile and one of the reasons is because human embryos produce many invisible genetic abnormalities and they do so even in normal menstrual cycles when the ovaries have not been stimulated. One of the problems with ovarian stimulation is that it increases the risk of some eggs which looked normal having chromosomal or genetic abnormalities.

So I completely understand and greatly sympathise with your predicament. I don’t know whether you should go on with treatment or not but it will be very difficult to stop when you have frozen embryos in storage. It is worth bearing in mind that the freezing process itself slightly increases the risk of a good-looking embryo not implanting. So ultimately I have to say that I think you need to reflect carefully on whether or not you want to go through this anxiety and this uncertainty again. If you don’t, you will certainly have a period of great sadness but you will have your amazing daughter on whom you can focus. If you do go through with treatment, you will at least have had the satisfaction of thinking that you have done everything to try to give your daughter a baby sister or brother.

By the way – I would be disinclined to change clinics. Better to stick with the people you know and who know you and have all your records.

My warmest wishes to you
Robert Winston

 

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