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The Importance of Individualized Care
The treatment of infertility, especially when using in Vitro Fertilization, can be a difficult process. It is a process that can be conducted in many different ways, depending on the philosophy of the doctors responsible for determining the protocol that will be used. We have found after more than twenty years in the field, that the best approach is one that maximizes the chances of success in each individual, by taking into account the fact that each woman is different and should be treated that way.
The concept of individualized care is based on the fact that there is tremendous variation in the fertility potential among women. Fertility potential refers to the ability of an individual to get pregnant, which in terms of IVF success is defined by the number of genetically normal eggs present in the ovaries. Age alone is not a very good way of determining this fertility potential because women start life with varying numbers of eggs, and at any given time in their lives, an individual may have more or less than the average number left depending on how many she started with. We have seen women barely out of their twenties who have few eggs remaining and are functionally menopausal, and occasionally women in their mid-forties who have more than twenty eggs retrieved during in vitro fertilization. As a consequence, it makes little sense to treat all women with the same protocol or medication dosage if the goal is to maximize success.
The number of genetically normal eggs available varies from woman to woman and even in the same woman from month to month. It is important to take this into consideration when determining whether to start treatment in a given month and how to conduct this treatment. We use the number of follicles present in the ovaries, as determined by ultrasound on day 3 of a natural cycle, and the FSH and Estrogen levels on that same day to determine whether or not to start an IVF cycle. The number of follicles present correlates pretty well with the number of eggs that will be retrieved that month. The FSH level is an indication of how easy or difficult it will be to stimulate the follicles to grow. These both can vary month to month. Sometimes it is necessary to monitor a woman for several months before finding the right time to start an IVF cycle. This is especially important in older women who have fewer eggs to start with.
It has become popular in some centers, to place all women on birth control pills as the start of an IVF cycle. This may be fine for women with a lot of eggs but it does not work very well for the women with fewer eggs. Birth control pills are used to help coordinate the start of an IVF cycle so that the egg retrieval procedures of a group of women will occur at roughly the same time, making it easier for the doctors and laboratory. For the women with fewer eggs however, the suppressive effects of the birth control pills can limit the number of eggs that are retrieved and leads to the use of much more medication in the process. The end result is a less successful and costlier treatment. By using birth control pills you are also losing the benefit of starting a cycle during a time when the number of follicles is maximal, since the pills are often given for 1-2 months. We see that even with younger women like egg donors who have been on birth control pills for a long time, their ovaries have many fewer follicles than they do after stopping the pills for a month. For this reason, we seldom use birth control pills at the start of an in Vitro Fertilization cycle. Instead, we prefer to monitor each woman in a natural cycle, thus allowing for the maximum number of eggs to be retrieved. This not only makes the chance of success better, but also keeps the cost of medication down.
The other important component of individualized treatment is the process of close monitoring during the stimulation phase of the IVF cycle. Every woman responds differently to the medications that are given. For this reason, it is important to monitor frequently both with ultrasound measurements of the follicles as well as the Estrogen level in the blood as the treatment progresses. This is the only way that important changes in the medication dosage can be made and the precise time that the eggs are ready to be retrieved can be determined. In some centers, the egg retrieval procedure is scheduled before any medications have been given. Some centers perform only one or two ultrasounds during the entire process. This completely ignores the individual differences that exist among women and can lead to either retrieval of too few, immature eggs or in some cases, dangerous hyperstimulation of the ovaries, which may necessitate hospitalization. We have always monitored at least every other day during the early stage of ovarian stimulation and then every day at the end, so that we can ensure that the eggs are retrieved at the best time for them to be fertilized. This also keeps the procedure as safe as possible at all times.
When consideration is given to the many ways in which an IVF cycle can progress among different women and even in the same woman at different times, it is easy to realize the importance and benefits of individualized care. Although the delivery of individualized care often means that convenience for the doctor is sacrificed, the end result greatly justifies the extra effort. We have always believed that when couples have to sacrifice so much to undertake an IVF cycle in the first place, we owe them the best effort possible. The results we have enjoyed over the years due to this approach have made it more than worth it for everyone involved.