Knocked Up Podcast - Navigating Assisted Reproductive Treatment (ART) Outcomes
Dr Raelia Lew discusses the potential outcomes of fertility treatment
In this episide we discuss the outcomes of Assisted Reproductive Treatment (ART) and IVF.
Key topics covered in the podcast include:
Possible outcomes of ART: pregnancy, unsuccessful treatment, biochemical pregnancy, miscarriage, and ectopic pregnancy.
The process and timing of informing of treatment outcomes.
The importance of review appointments with your specialist after treatment.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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TRANSCRIPT
Dr Raelia Lew:
Women’s Health Melbourne is an innovative, holistic fertility and women’s health practice. We are world leaders in IVF and egg freezing and provide our patients with every opportunity to achieve their goals.
Jordi Morrison:
Our handpicked expert team provides the ultimate care experience for our patients. Reach us at womenshealthmelbourne.com.au and follow us at Women’s Health Melbourne and at Dr Raelia Lew.
Hello and welcome back to Knocked Up, the podcast about fertility and women’s health. You are joined as always by me, Jordi Morrison, and Dr Raelia Lew, CREI fertility specialist. Today, we're discussing the outcomes of ART and/or IVF.
Raelia, we're always talking about the treatment itself rather than the outcomes. Why is this topic important to discuss with our community?
Dr Raelia Lew:
Thanks, Jordi. I think it's important on so many levels. In fact, I just returned from the Fertility Society of Australia and New Zealand annual conference in Perth, getting in late last night from there.
Jordi Morrison:
You did? Big few days you’ve had. Very exciting.
Dr Raelia Lew:
Actually, very important things were discussed at the conference, with the former Health Minister, Greg Hunt, sharing a review of Australian and New Zealand plans for assisted reproductive technology going into the next decade.
One of the things that was discussed is how outcomes are reported in IVF and the limitations of that. And actually, I stood up at the conference and pointed out that maybe we're not looking at the correct outcomes when we are discussing IVF — that we're talking about outcomes per cycle as opposed to outcomes per person. And really, the outcome a patient wants to know is: am I likely to have a baby, not am I likely to get pregnant this month?
So we maybe just need to shift our whole paradigm of how we think about IVF outcomes to be more patient- and person-focused rather than driven by Medicare item numbers that reflect a month of treatment. Because the reality for most IVF patients is it’s a journey, not one encounter, and not everyone gets pregnant every time they try, unfortunately.
And the best case scenario is that fifty percent of your patients will get pregnant in a given month. That’s best case scenario if you're dealing with a really young and good prognosis cohort. And the reality is that the cohort of patients that we generally treat in IVF have problems — and that's why they're there. So they’re likely not to have those amazing stats. They're likely to have more like a one in three or one in four chance of getting pregnant every time an embryo goes back.
And so I think we really have to take one step back and think about: what is the chance of my patient having a baby? And even one step back further: what is the chance of my patient achieving the family that they ultimately want over a number of years, not in a Medicare calendar year?
So I really do believe, truly and strongly, that we just need to take a step back. And I think sometimes the statisticians and the government organisations and even the fertility society organisations — we're so used to and institutionalised into thinking a certain way — that sometimes our paradigm of how we think can let patients down. Because we’re not using the benchmarks of success that are meaningful to patients trying to have a family.
Jordi Morrison:
I think what you said there reminded me of two things that you say not infrequently — and on this podcast as well. One is that in many cases, the first round of IVF is diagnostic, and I'm sure we will talk about that more. And the other is, you actually made the point of saying “having a baby,” not “getting pregnant.”
Dr Raelia Lew:
Yeah. Well, that’s what people want, isn’t it?
Jordi Morrison:
Absolutely. Should we go through what are the possible outcomes of ART, or assisted reproductive treatment?
Dr Raelia Lew:
Yeah. Well, I think in terms of the first big picture outcome, you either get what you want or you don’t. So you either have a baby or you don’t. But along the way, when we try and get somebody pregnant — by doing an embryo transfer, for example — there's going to be more potential categorizations within those two categories of “pregnant” and “not pregnant.”
Within the category of becoming pregnant, you may have a pregnancy that’s ongoing and leads to a live birth, and that’s the ideal outcome that we all strive for. But there are many possibilities. You may have a pregnancy test that is positive but that doesn’t result in a live birth ultimately. And within that category, you may have a pregnancy that’s what we call biochemical. That means that you get pregnant, but you don’t hold the pregnancy — and it doesn’t necessarily continue even to the point where an ultrasound can diagnose where the pregnancy is.
Dr Raelia Lew:
Now most of those pregnancies are going to be in the uterus where they should be, but some of them can be outside of the uterus, and they can be ultimately what we call an ectopic pregnancy. Ectopic just means something somewhere it should not be. So it could be in the fallopian tube. That’s the most common place that an ectopic pregnancy can be, and that’s because when an egg and sperm meet, that’s where they meet — in the fallopian tube. The egg’s on its way down and the sperm’s on its way up, and they meet in the middle, like the bridge between the pelvis and the uterus itself.
So from that perspective, an embryo along its journey can take a detour or have a holdup and not get where it’s meant to go all the way down to the uterine cavity. And it can then decide that, hey — I’m ready to implant, and I’m going to have a go at implanting in the wrong place. One of the problems with ectopic pregnancies in the fallopian tube is that the fallopian tube, unlike the uterus, is not designed to expand and compensate for a growing pregnancy. It does have an excellent blood supply. And so if it expands and bursts, it can bleed profoundly. So it’s a dangerous place to have a pregnancy.
Unfortunately, even if it’s a good embryo that could ultimately have made a baby if it was in the right place, it has no chance of success due to the location of where it has attempted to implant. So unfortunately, a pregnancy in the tube represents an inevitable pregnancy loss, and our focus as doctors switches to be 100% on maternal safety and trying to ensure that the mother doesn’t have a dangerous outcome.
A lot of women who contemplate surgical management of ectopic pregnancy — removal of a tube — feel deeply wounded by that idea. Because in the mind of a woman, in the mind of a patient, losing a fallopian tube is not only losing the current pregnancy, which is a pregnancy they had up until that point been very emotionally invested in, it also represents the potential loss of future pregnancies that might have been conceived using that tube. And it also represents really a switching gear for many people — from the idea of trying naturally to conceive to really needing a lot more help. So it’s a difficult, difficult scenario.
There are lots of different ways to manage ectopic pregnancy — surgically, medically, or expectantly — and we’ve got a whole episode on that in our Knocked Up back catalogue. So people who want to learn more about ectopic pregnancy can have a listen.
Aside from in a fallopian tube, you can have ectopics in other places. You can have an embryo that traveled all the way out the other end of the tube, took a wrong turn, and went into the abdomen. That’s incredibly rare, but it has happened in the world to some people, unfortunately. And you can have ectopics that stick in other places where pregnancies can’t continue — like within the scar of a caesarean section, for example, or at the very top of the fallopian tube where the tube is more muscular.
It’s called a cornual ectopic or interstitial ectopic. And that type of ectopic pregnancy is also, unfortunately, a dangerous type of ectopic pregnancy.
Dr Raelia Lew:
So that can be one outcome. The other outcome that’s unfortunately quite common — will affect one in five women at least when we're young and actually up to nine out of ten women when we're over 45, and probably more like one in two around the age of 40 — is miscarriage. Miscarriage is when a pregnancy implants in the correct location, but the pregnancy itself is not going to make a baby.
There are multiple reasons that a pregnancy can miscarry. The two main reasons fall into a developmental category, and that’s either having the wrong chromosomes — the wrong DNA — to make a normal baby. That’s called chromosomal aneuploidy, and that, unfortunately, most of the time results in inevitable miscarriage. So that pregnancy, although in the right place, although supported by the mother, it’s an embryo problem, and it’s never going to proceed to a live birth.
And the other category is when a pregnancy is genetically normal but not developmentally competent. That’s when the plan is written correctly but not implemented correctly in terms of creating a baby from the DNA blueprint. Those two categories really represent developmental concerns.
There’s a third category, which is when the environment of the uterus is hostile to implantation — or at least not helpful to implantation. That’s when a miscarriage can happen because of environmental reasons. It can be immune-related, such as in the syndrome antiphospholipid syndrome, where the maternal immune system can launch an attack on the placenta. It can be related to a hormone support problem, where there’s inadequate progesterone to support a pregnancy in that vulnerable time between when the pregnancy implants and when the placenta becomes autonomous in the first trimester.
So those are the reasons for miscarriage, and it’s really common. And it becomes more common as we get older because the aneuploidy-related miscarriages happen more frequently at an older age. It’s related to egg age, not maternal age.
Jordi Morrison:
Yeah. And I think we’ve talked about miscarriage a bit before, and it’s absolutely no one’s fault. There’s nothing you can do or not do that would bring this on or save the embryo. It just happens. And as you’ve said, as you get older, there’s a higher chance of that.
Dr Raelia Lew:
That’s right.
Jordi Morrison:
We’ve just been through all potential outcomes. If there is bad news, how will the patient hear it?
Dr Raelia Lew:
One problem with IVF is that we have many points where you can have what is perceived from a patient perspective as being bad news — and I guess, you know, that’s a relative consideration. So you might have bad news in that, in the course of your ovarian stimulation, fewer follicles respond than you would have ideally liked to have. That would probably be delivered via the nursing team or sonographer or from your specialist at that point in time, depending on who’s doing your ultrasound scan and how much feedback they give you.
It’s important to give that feedback, actually. It’s not necessarily what I would call bad news, but I would call it expectation setting, because you’ll never get more eggs than you have follicles responding in a cycle. So if you have an expectation that you’re going to have ten eggs collected but you only have five follicles, well, that expectation is unrealistic. I think realistic expectations do set yourself up for more of a stable journey from egg collection to the end of the IVF cycle — whatever that outcome may be.
Then what happens is at the time of your egg retrieval, usually the doctor doing your procedure will alert you to how many eggs we’ve collected. Again, that’s another opportunity for those numbers to go down, because not every follicle has a retrievable egg or an egg of quality.
And then the next day, we say how many eggs have fertilised normally. Some eggs don’t fertilise at all, and other eggs fertilise normally and look perfect. Others fertilise what we call abnormally and look unusual. Sometimes, if you’re doing ICSI, some eggs burst open when you inject them — that’s called lysis or degeneration. So the outcome of how many zygotes — or normally fertilised single-cell embryos — we have is given the day after the egg collection, and that will usually be delivered by a scientist.
Usually, laboratory updates — whether they’re throughout the course of embryo development or just at the end — are going to be delivered by a scientist. And they’ll be able to, in our practice, explain to patients a little more nuance of how the eggs, sperm, and embryos behaved over the course of that week.
Dr Raelia Lew:
Quite often, if a patient’s having a fresh embryo transfer, the outcome of the cycle from an embryonic perspective is not yet known because there’ll be some embryos that are watched for an extra day. Usually, when we do an embryo transfer in a fresh IVF context — so we do an egg collection and embryo transfer in the same cycle — we’ll do that on day five after egg collection. And often the outcome of all embryos is not known for at least another 24 hours. So sometimes that update — whether there is something to freeze or not in addition to the transferred embryo — is also going to be delivered by a scientist.
And if we’ve had an embryo transfer, be that fresh or frozen, the outcome of that attempted pregnancy is not going to be known for a further at least ten days if it’s a blastocyst transfer, and more like fourteen days if it was a cleavage stage embryo transfer. That’s why it’s called the “two week wait,” because when all the terminology of IVF was coined, we used to do predominantly cleavage stage embryo transfers. So it was a two-week wait between the transfer and the pregnancy test. Now it’s more like ten days.
That pregnancy blood test is usually attended at a pathology collection centre, and the outcome of results is known several hours later. Usually, that falls to our IVF nursing team — to both chase the result, find it, and deliver it to the patient, whether it is positive or negative. And even there, there is nuance.
So if it’s a negative test result, that is the end of the cycle, and that attempt at getting pregnant from that embryo transfer is known to have not been successful. However, there may still be some other potential outcomes that could lead to future success from that cycle, such as embryos banked in the same egg collection, and that might ultimately result in a birth.
That patient who’s had an embryo transfer will be at a crossroads as to what to do next. They’ll be considering whether they should have another full IVF treatment and try again the same way and have the opportunity to bank further embryos. Perhaps they have a frozen embryo, and their next step might be an embryo transfer. They might feel emotionally ready to move on directly, or they might need a little break. Quite often, that’s an excellent opportunity to catch up for a review consultation and have a big-picture conversation: Where have we been? Where are we now? Where are we going?
And just align and make sure that everyone’s on the same page. Also, if a pregnancy hasn’t occurred, we always take a moment to step back and say, “Well, is this the embryo? Could it be another factor? Should we try again with a different embryo, or should we do something further to investigate or to change the way that we are attempting a pregnancy?”
There’s been some really good science reported — not just in Australia, but worldwide — in the last few years that’s really clarified significantly: most of the time, the problem is the embryo. It’s either not had the right ingredients to make a baby or not done the right thing. More than 60% of the time when a pregnancy does not work, it is the embryo. And really, from a medical perspective — from a logical perspective — what needs to happen next time is an attempt with a different embryo. And that is doing something different.
Dr Raelia Lew:
Sometimes it is doing something different. You might not be changing everything — it is literally a different embryo. DNA. It’s got a different combination of genes from the parents, and it’s also got a different developmental opportunity to do the right thing. Sometimes that is what the right next step is. I think sometimes patients don’t necessarily fully grasp that. I think it’s about power.
Jordi Morrison:
Oh, and I think it’s about wanting action. Right? It’s like, well, that didn’t work — let’s try something else.
Dr Raelia Lew:
Power. And I think it’s about human nature. Because what I mean by power is we like to have control. We like to believe that we have control. That is something that is very soothing and helpful to us, because it means that we can change our actions — which is within our power — and we hope that that will change our outcome. A lot of us are very used to that in other spheres of our life: things that I can do that will make things different.
Unfortunately, embryonic development — fortunately, also miraculously — is completely outside of our control. We can’t control what the embryo does when it goes back. The fact that it has the potential to create human life is unbelievable and amazing and beautiful, but we don’t control it. We’ve got to roll with it.
And if we have made sure that everything else is fine, it does most of the time come down to the embryo. Now, when it doesn’t come down to the embryo, what can it be? There are other things it could be. It could be an environmental concern — things like structural anomalies of the uterus, or chronic inflammation of the environment of the endometrium (endometritis). Those are things we need to know about, and things that we need to suss out.
Usually, hopefully, we’ve done that at the beginning. But sometimes they are evolving concerns. So we look into them as they come along. Hopefully, we’ve done a really broad sweep of investigations right at the beginning of treatment. I know in our practice, that always happens, so that we at least find the obvious things early — things we can address and change.
But even where everything has been totally optimised, it still comes down to the embryo. And that’s where it also comes down to the quality of the embryo — but also, a normal embryo doesn’t always do the right thing. It’s a matter of time, often. Sometimes I say that to patients when they are in that circumstance — that I’m confident you’ll ultimately succeed, I just can’t tell you exactly which embryo it will be that will make your baby.
Jordi Morrison:
So after hearing bad news — as we’ve said, it could be a few different things — but in the case of not being successful in getting pregnant, your patients have a review appointment with you. What’s the main takeaway from that appointment that you’re hoping the patient gets?
Dr Raelia Lew:
Really, it is very individual, and circumstances are different for different people. Sometimes it is a matter of a quick phone call. If someone’s had one embryo transfer, they’re not pregnant, and they’ve got many other embryos in storage — and they’re relatively young, and we’ve looked into other things, and there’s not anything significantly the matter — we just acknowledge that not every embryo makes a baby. That it’s going to be, on average, one in three embryos that does, and we have another go.
Sometimes at the beginning of the journey, that’s not — it’s a disappointment that you’re not pregnant — but it’s actually an expected outcome out of the possible outcomes of the cycle. Hopefully, my hope is that I’ve prepared patients emotionally from the beginning, before they’ve even had a single attempt, so that they’re aware of the possible outcomes. Because, you know, IVF always is a marathon, not a sprint — as is pregnancy, as is trying naturally for many people.
And we just have to be aware of that biology, because then it becomes, I guess, an expected possibility — and we deal better with those. So it’s about being empathic. It’s also about, particularly for very good prognosis patients, where it is just a matter of time — it’s a matter of when, not if — and just encouraging them to remain hopeful and supporting them.
It’s also really important — and I try to do this in my practice — that when a patient does have a lower prognosis of success, that I’m very candid about that and transparent about it from the beginning. There are a subset of women, particularly in our forties, who are very realistic about the fact that they are trying for a baby later in life.
And we know that egg quality is a major issue and a major obstacle. And it’s a difficult demographic, because we help so many people have babies with their own eggs in their early to mid-forties through persistence and perseverance, and through a hope for themselves and a belief in themselves — and also through good luck, because you need that as well.
There’ll be an equal number of women who try very, very hard — who are demographically identical and do nothing different — who unfortunately will not get there with their own egg because, for them, it’s been too long. And we need to also support those women realistically about other options. Quite often, egg donation is the solution. But it’s not necessarily an emotionally easy pivot, and it’s not for everyone. Some people can’t cope with the notion — and that’s fine.
Dr Raelia Lew:
So I guess how I support every patient is different. I take into account their circumstances, their prognosis, their personality, and also what they need to do next. I also think it’s important for people who have been through serial IVF to have the opportunity to get off the train. I think sometimes you can try and try and try — and it’s okay to decide not to continue, for some patients. Sometimes they need not the permission to do that, but also the support to be able to recognise that that’s where they’re at, and also the support in coping with the downstream ramifications of that decision.
So I think it always is important to touch base and have these conversations — also just to make sure nothing’s been missed. Because as we are evolving, and medical conditions evolve, they can progress, and the ageing process also affects people. Sometimes a condition that wasn’t apparent at the beginning of a set of investigations has evolved and has developed and has become relevant. Or maybe it always was relevant, but it wasn’t evident on the basis of earlier investigations.
So it’s really important to step back, re-evaluate with a fresh pair of eyes, and also evaluate where someone’s at physically and emotionally — and what the best next steps are for them.
Jordi Morrison:
You talk a lot about how, as a fertility specialist, yes, you’re the key doctor and the captain of the ship — but it takes a team. I would think when you’re trying to get pregnant, you need to grow that team to support you, because the chance of a bad outcome is more likely than a good outcome, certainly initially.
Who do you recommend that a patient has in their team? So you’ve got close friends and family who you may or may not be speaking to about this, but who should you have on board to support you?
Dr Raelia Lew:
It’s interesting. I don’t know if the conversation was about fertility, but I was talking to a friend the other day, and they were talking about how they were going to a city where they had a friend — an old, old friend. And so they looked their old friend up to say, “Hey, I’m going to be in town.” And her response was, “I’d really like to see you, but I’m not in a place at the moment where I can really talk about the things that are going on in my life. Hopefully, you’ll forgive me, but I don’t want to catch up.”
And I thought when I heard that story — well, maybe they’re going through a fertility journey. Or it might not be — it might be another life event. But, you know, I think sometimes what we need is not someone, but space. So that’s also important.
But look, I think the old adage that “a burden shared is a burden halved” is true. With the right supports, communicating your circumstances to those who are close to you can be very helpful, because they offer you emotional support. Sometimes they offer unsolicited advice, and that’s sometimes difficult as well.
Professionally, a supportive counsellor can be very helpful because they won’t be offering unsolicited advice, and they won’t be appearing on your doorstep with a casserole when you need personal space. So it is good. And they do have that training of having looked after and cared for thousands of people — usually over the course of years — who may not be in the identical situation but who have been through similar emotional challenges.
Dr Raelia Lew:
And their job is also to equip you as a patient with the skill set to deal with things in a healthy way. Because we can’t, unfortunately, unburden patients of the emotional challenges of IVF — they are universal. But we can support you through it and give you the coping strategies to help you traverse those challenges with a more supportive structure around you.
In terms of our network within our practice, we have our counsellor. We have our nursing team. Nurses, like doctors — as I mentioned about every day bringing joy and bringing pain — they have that experience as well. And I think patients sometimes don’t appreciate necessarily — I’m sure our nurses are very much appreciated by patients — but I think probably patients don’t appreciate necessarily the amount of emotional energy that a nurse expends in a day of treating patients. Because they really shoulder the load of not just the patient themselves, but the other patients all at once who are in treatment.
And it’s not just the patient who’s had the bad news — unfortunately, the negative pregnancy test. It’s also the patient who’s deeply nervous about embarking on a first treatment. And it’s the patient who’s had some confusion in terms of what to do with their medications and might have some anxiety that they’ve made a mistake. Or, you know, it’s all kinds of emotional concerns and challenges.
As a fertility nurse, every single day you will have your task that you need to efficiently and effectively perform, but then you’ll also — from all directions, all through the day, at all points — have unexpected patient questions and needs to meet coming out of left field, even though in your diary you’re meant to be doing something different. So I think our nurses often know they have to be like an octopus with eight arms catching multiple balls in the air all at once.
I deeply appreciate everything they do, with such deep empathy and care. And I think they’re an absolutely critical part of any IVF team.
Jordi Morrison:
So this episode might sound a little bit negative, but as always in fertility, there’s some light. What is something good you want people to keep in mind when they’re going through this?
Dr Raelia Lew:
I would say that when a patient has a terrible prognosis — where I think they’re unlikely to succeed — I will tell them that from the beginning. So if you are in treatment, it means that I believe there is a chance that you will succeed. And most of my patients will ultimately succeed. It may not be this month, but ultimately, most patients in IVF with a reasonable prognosis will succeed if they remain in treatment. And one of the goals of support is to keep someone going so that they can ultimately succeed.
Jordi Morrison:
Love that. Thank you, Raelia.
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