When you are starting an IVF cycle, the first step is starting daily hormone injections to stimulate the growth of follicles in your ovaries. After 8-10 days of injections, when the follicles have grown to an appropriate size, an injection is given for final maturation of the eggs known as a trigger. Thirty-four to thirty-six hours after the trigger injection, the procedure of egg retrieval is done under short general anesthesia. On the day of egg retrieval, the eggs are mixed with the sperm. Next day they get fertilized. Then they grow to the embryo stage. The embryo transfer is done on the second, third or fifth day after egg retrieval.
Your IVF cycle may not be completed due to cancellation at various steps.
We will discuss them one by one. Sometimes your IVF cycle may be canceled in this initial stimulation phase. So what may be the reasons for doing so?
1. Ovarian cyst: – When the doctor does an ultrasound scan on the 2nd day of your periods, there may be a fluid-filled sac known as a cyst in your ovary. This would hamper the growth of eggs in the ovaries. So the IVF cycle in that month is canceled. The doctor may give you medicines like oral contraceptives or antibiotics to suppress it. In the next menstrual cycle, ultrasound is done again to check the ovaries. If there is no cyst, we can go ahead with IVF.
2. Poor response: – If there is a poor response that means either very less number of follicles like one or two or no growth of follicles, the further course of action depends on various factors.
If you are young in age with good ovarian reserve, good AMH levels and normal levels of follicles in ovaries, the doctor may decide to cancel this cycle and try with a change in medicines or injections in next cycle. If there are one or two follicles and your fallopian tubes are healthy, a husband semen analysis is normal; the cycle may be converted to IUI cycle.
If you have advanced age, your ovarian reserve is low; either you can continue the same cycle. We can collect the eggs in 2-3 cycles, make embryos and then transfer them inside your womb. Or we can cancel this cycle and the doctor will try changing your medicines, their dose, etc in the next cycle, but there is no guarantee there will be a better response in next cycle or you can opt for using donor eggs.
3. Hyper-response: – There has been changing evidence about the optimal number of eggs required to achieve good success rate with IVF. Now we currently aim for 10-15 follicles. A follicle number of 5-9 is suboptimal and 4 or less is the poor response. But sometimes we see a lot of follicles have started developing on giving hormone injections. This is especially common in young patients and those suffering from polycystic ovarian syndrome (PCOS). This hyper-response can lead to a condition known as Ovarian Hyperstimulation Syndrome (OHSS). OHSS can vary in severity from mild to severe. In mild OHSS, the patent may have mild abdominal pain or heaviness, bloating, nausea, vomiting, diarrhea, etc. In severe OHSS the patient may have severe pain abdomen, decreased urine output, develop clots in legs, etc. The doctors want to avoid this condition as much as possible. To deal with the hyper response, we can cancel the cycle. But the hyper response is not always avoidable. So we can use a GnRH agonist trigger and take out the eggs. Then the embryos are formed. Those embryos are not put back into the womb, but they are frozen. After a month when the ovaries have gone back to their normal size, those embryos are transferred.
4. An unexpected drop in Estradiol levels: – If there is an unexpected drop in estrogen levels or the growth of follicles stops or regresses, the doctor may feel we won’t get viable eggs and cancel the cycle.
5. Illness: If you develop some serious illness unrelated to IVF like dengue, swine flu, etc or may be related to IVF like clots in your legs like thrombosis, etc, the IVF cycle may need to be canceled. We will start the treatment again after you fully recover.
6.Personal reasons: You may cancel the cycle due to psychological or financial reasons. If you share your problems with your doctor, they will help you with a psychological counselor.
Your IVF cycle may be canceled because we have no embryos to transfer.
This may happen in the following cases:
- No eggs are retrieved: this may happen if the trigger injection is not taken properly or there are a low number of follicles or all the follicles are empty.
- No eggs are fertilized
- No embryos are formed
- If Preimplantation genetic screening is done to check for chromosomal abnormalities, there may not be any genetically normal embryos to transfer.
In all these conditions the doctor will check for the reason it happened.
- The next time there may be a change in the type of injections, their dosage.
- The trigger injection needs to be taken correctly.
- In case of failed fertilization if IVF technique was used previously the doctor may use Intra Cytoplasmic Sperm Injection (ICSI) next time.
- There may be an issue with the quality of eggs or sperm and you may need donor egg or sperm.
Even after the embryos are formed, there may be no embryo transfer.
So what might be the reasons for canceling an embryo transfer?
1. Freeze all embryos: – As we have discussed above, to avoid developing Ovarian Hyperstimulation Syndrome (OHSS), the doctor may decide to freeze all embryos and transfer them in a subsequent cycle.
2. Fluid in endometrial Cavity:-There might be fluid in the endometrial cavity on an ultrasound which hampers the implantation of embryos. So the embryo transfer is not done. There can be many reasons for this fluid but commonly it is due to infection of the lining of the uterus (Endometritis) or due to the presence of Hydrosalpinx. Hydrosalpinx is a collection of fluid and dilatation of fallopian tube due to blockage of fimbrial end of the tube. So we have to treat the cause of this fluid in the endometrial cavity and then plan an embryo transfer.
3. Difficulty in Embryo transfer: – We do a mock embryo transfer in the previous menstrual cycle to check that we can pass the embryo transfer catheter (a thin plastic tube) into the uterus, and to know about size and direction of the uterus. So that we are prepared at the time of actual embryo transfer which has to be done very smoothly and gently. In spite of having an easy mock transfer, the doctor may face difficulty in passing the catheter inside the uterus at the time of actual embryo transfer. He/ She may decide to defer the cycle and plan a hysteroscopy before planning the next transfer.
4. Endometrium (Uterine lining) not developed properly: – Sometimes the lining of the uterus known as the endometrium is too thick or too thin or doesn’t have the required appearance/ echotexture on ultrasound which may decrease the success rate of IVF. The doctor may decide its best to plan embryo transfer in a subsequent cycle.