When IVF doesn’t work
A common concern for couples involved in IVF treatment
is what will happen if IVF doesn't work. Does the
failure of IVF spell the end of your parenthood
journey? Dr Richard Fisher explains the possibilities
What to do when IVF doesn't work is a much more complex question
than it first appears. The answer to the question depends as much
on the circumstances that led to the initial treatment as it does
on why that treatment may not have worked. As well as what
might be possible comes an associated question as to what might be
wise, in terms of future treatment. That will depend on the
emotional robustness of the couple having treatment as well as the
resources available around them to support whatever choices they
make. One of the difficulties that infertile couples have in
dealing with their peers, friends, and families is often a failure
of those groups to understand the complexity of the myriad of
choices that follow any particular treatment, whether it succeeds
or fails.
With the continuing changes in the quality
of embryology (the way that the embryos are grown and developed in
the laboratory before being transferred into a woman's
uterus), the cumulative chance of conception after a small number
of treatment attempts with IVF can be quite high. For the average
woman under the age of 38, it will be as much as 80-85% after three
attempts. The range around that number will depend on the
individual, although it is very rarely possible to know who was in
the "better" or "worse" group before a number of treatment cycles
are completed. Clearly there are constraints to access for such
treatment, with public funding being limited to up to two cycles of
treatment providing certain criteria are met, and private treatment
being costly enough that a significant number of couples cannot
contemplate it. Nevertheless, if continuing with treatment is
possible, most younger women will end up conceiving.
What to do after any particular failed
treatment cycle of IVF will depend on the background. Young women
will normally be encouraged to try again. Only a very few young
women will learn during treatment that either they or their
partners have such a complicated problem that the advice would be
to stop. Couples with high expectations of success commonly find
failure a much more devastating circumstance than do those whose
expectations are not so high.
The consequential emotional toll that
failure of treatment has will determine their future actions. For
some couples, even continuing low chances of success will not lead
them to decide to stop treatment. The job of the reproductive
medicine specialist, therefore, is to ensure that couples are
absolutely clear about the likely chance of success, and just as
importantly, the escalating emotional toll that recurrent
failures can cause.
The availability of good information and a
readily accessible counselling service is a very important part of
reproductive medicine practice. Older women may have made the
decision to try IVF in the hope of conception using their own
gametes (eggs and sperm), but in the knowledge that if this doesn't
work, the use of somebody else's donor eggs might be a back-up
option. Similarly, this can happen in couples where the primary
problem is a male one. These days, we can use very small numbers of
sperm to fertilise eggs, using the process of intracytoplasmic
sperm injection (ICSI), but if the complexity of the treatment
proves too daunting, or recurrent attempts lead to continuing
failure, then the option of donor insemination may
remain.
It is important to remember that although
IVF has the best chance of success in any particular month
of trying, the decision to do IVF is often made where there is
a continuing month-by-month chance of success naturally, even if
this is quite small. The decision to stop IVF treatment,
therefore, does not preclude pregnancy occurring in the
future. For some couples, the need to make a decision whether
to start using contraception or not becomes a real dilemma. As
long as the chance of pregnancy remains, the stresses that go
with sub-fertility will remain too.
Most couples who have required complex
treatments to conceive allow themselves around a nanosecond of joy
before they convert that joy into an anxiety about the likely
outcome of the conception. It is impossible to be involved in
treatment of sub-fertility without understanding that not all early
pregnancies continue and the risk of miscarriage is very real, even
though it is no greater than natural conception. For many
women, finally reaching their apparent goal just converts one set
of anxieties into another. This is an entirely normal response, but
one which friends and families need to understand and empathise
with. The urge to be positive and supportive needs tempering by the
knowledge that sometimes, "almost but not quite successful" is
worse than "not at all". Children born to IVF parents have very
normal social outcomes, but these parents' history of delayed
conception and sometimes multiple treatments may cause these
anxieties to linger even beyond birth. The birth of a child is not
a cure for infertility. The fact that couples may not be able to
conceive by themselves without help is a cause for continuing grief
for many families despite the joy of successful treatment. Having
only one child may not be the aim of this family, and the stresses
of the prospect of starting treatment again are difficult to
ignore. Furthermore, the hard work of early parenthood is no easier
for those whose pathway to conception was more complex than it is
for those who conceived without difficulty. The fantasy of new
parenthood may not match reality.
Infertility is about loss. Sometimes, the
loss of things you never had or whichyou might be denied is every
bit as acute as loss of things you had already gained.
Understanding this allows one to support couples with sub-fertility
more effectively.
Obvious losses such as miscarriage or
stillbirth are often greeted with empathy, flowers, and visits.
Less obvious ones, like treatment failure for infertility,
are often met with silence. The decision to leave active treatment
behind and refashion life into the future is never an
easy one. It inevitably involves despair, self-doubt, and lots of
tears. For a couple who so desperately wanted to conceive a
child but couldn't, the loss is enormous. Children are all around
us, and children with seemingly poorly motivated parents are more
obvious than we would really wish. They are a daily stark
reminder to infertile couples, and it is not possible to
quickly switch off a desire for children and look to a different
future. Support, both professional and personal, is
important.
There is a need to find ways to live with or
settle this grief and the concomitant anger and resentment which
may commonly be present. Envy and bitterness are normal responses
which need to be dealt with. Sometimes, the time that couples have
tried to get pregnant prior to fertility treatment, added to the
time treatment was occurring, is such a significant part of their
lives that the adjustment to a non- "fertility searching" life
proves very difficult. In time, a decision to leave treatment
behind can, for some, be quite liberating, and allows them to look
forward positively to alternative ways in which they will lead
their lives. Relationships that have been built around the quest
for conception will need redefining. A refocusing on areas of
relationship growth can create an entirely positive environment for
the couple. Deciding not to have further treatment should be the
end of a particular expedition, not the end of the journey. In
time, reflecting on this expedition should be at least a neutral
event, not a negative one. If it is not, people like me will have
failed in their task.
For many, a closer and more involved
relationship with nieces, nephews, and cousins might provide a
positive experience, both for them and for their wider family. The
desire for a more immediate relationship may lead to the
consideration of adoption or fostering.
The process of adoption, sadly, is no less
stressful than complex treatment. There are very few newborn
children available for adoption in New Zealand, and the process of
information, assessment, and potentially being chosen as an
adoptive parent is stressful and prolonged. Child, Youth and Family
(CYF) run courses on alternative ways of parenthood, which are
informative and realistic. Many couples find the information
enlightening, but the process unsettling, with its requirement for
social work assessment. Exploration of a couple's relationship and
circumstances can prove daunting. The instability of regulations
around overseas adoption, both in overseas countries and in New
Zealand, makes overseas adoption an equally difficult task. Some
ethnic groups within our community find sourcing potential adoptive
children somewhat easier, but the legal and social requirements
remain the same.
Fostering children is also handled through
CYF, but many couples who have found the stresses of infertility
difficult view the stresses of the transitory nature of fostering
as being just too hard.
It is entirely possible to live satisfying
and full lives without the presence of children. Some couples do
this by choice. There are many examples of people I have seen over
the years who have survived the disappointments of infertility to
live their lives enriched in other ways. Empathetic understanding
by those in contact with couples for whom childlessness was not
their forst choice will further enrich their lives.
Richard Fisher FRCOG, FRANZCOG, CREI together with Freddy
Graham established Fertility Associates in 1987 after previously
starting up New Zealand's integrated infertility medicine group at
National Women's. He is New Zealand's foremost medical
spokesperson on matters of reproductive health and has been an
advocate for better access to care for couples with
infertility throughout his career. He has four children and is
married to Leigh, without whom he could never have practiced
medicine with the enthusiasm and commitment that he has. Visit
www.fertilityassociates.co.nz
to find out more.
As seen in OHbaby!
magazine Issue 12: 2011
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