We all know that IVF works, but also it fails. When IVF fails, it can be very frustrating, often leading to anger, disappointment, dashed hopes, and sometimes a lot of blame being traded, because of everything that has been invested into it; money, time, and emotion. A cycle of IVF is akin to what happens in the human body in the woman in a month. Everything that we do in IVF is to replicate what happens in the woman’s body on a monthly basis. So a cycle is like what happens to a woman in a month. 

Human reproduction consists of two major steps, fertilization and implantation. Fertilization is the bringing of the sperm and egg together and implantation is the uterus accepting the embryo that has been presented to it. Let’s look at it from the point of planting a seed that germinates. We know every seed that you plant germinates, but in this case, the embryo will represent the seed and the lining of the uterus will represent the soil. It is when you see the germination or the sprouting of the seed, when it grows out of the soil, that you can say that you have succeeded. The same thing is when you say a pregnancy, or you can detect pregnancy, that is when we know that implantation has taken place. 

For this to happen, there must be some raw materials. We need good quality eggs, not just any egg. We need good quality sperm, and then we need the proper union of the sperm and the egg or what we call fertilization. IVF means In vitro fertilization, fertilization outside the body. So what happens in fertilization is that there is exchange of genetic materials between the man and the woman. So a lot of genetic factors come into play here. After the union of the sperm and the egg, what is needed are good quality genetically normal embryos. When you have good quality, genetically normal embryo, then your uterine lining needs to be of good quality. So that there can be interaction between the good quality genetically normal embryo and the lining of the uterus. This is where the experience of the doctor comes in., to do a smooth embryo transfer. 

After all these procedures, implantation can now take place. Which is just the synchronization between the embryo and the lining of the uterus. That is when you can have a successful IVF cycle. We know that the success rate of IVF when you are less than 35 is a peak, gives you about 30 to 40% baby take home rate and that decreases to 5% when you are about 40.

In the body naturally, a woman has a chance between 20-25% every month. In other words, IVF delivers better success rate than what nature itself can present. So IVF is a little bit more efficient than nature. We know that human reproduction is one of the most inefficient processes in the body. And this is not surprising because there are so many quality control systems in the body. This is why we can beat our chest and say that IVF babies are normal babies. 

Factors that determine the quality of eggs

• Age: Age is the most important factor in determining the quality of eggs.
  
• Drugs: So many clinics will devise ways because especially in our environment, where power is not stable, many people will devise a way to store drugs. The drugs must be properly stored so that the cold chain is maintained, and also, the administration of the drugs is important. If it is supposed to be under the skin, you cannot put it into the muscle, if you want to get the result that you want. One other thing about drugs is the timing. If it is 10 o’clock, then it better be 10 o’clock. If you use it at 11 o’clock for any reason, you must tell them at your clinic that you didn’t take your drugs at the appropriate time so that we know if we need to juggle things around. It is much better for you, to keep to the time that was allotted for the drugs. Then the stimulation protocol is of importance. You must use the right stimulation protocol and the right dosage of drugs in order for you to get good quality eggs. 
• The other thing we talk about is sperm quality. Age also contributes to sperm quality. When we talk about sperm quality, some people get it wrong. The function is what is important in sperm, not the morphology. Don’t forget that when we are doing semen analysis, what we look out for most of the time is the morphology of this sperm. We talk about volume, count, and morphology. But here the important thing is actually the function of the sperm, which we cannot find any test for now. But there are some other things that we can do.
• Then the exposure to very dangerous toxins. For example, people who smoke, gardeners who are exposed to chemicals and even some people who were exposed to radiation. There is something we call DNA damage, which we now see in men who were exposed to these toxins. For example, people who work in petrochemical industries. That is one thing we are also looking at, which might affect the quality of the sperm and its function.
• If the quality of the sperm and the quality of the eggs are not good, it might be challenging to have a baby. The embryo quality is so important. Sometimes the embryo looks normal but they are not good quality, genetically normal embryos. If there is any error here, this is where age comes in, if either the man or the woman are advanced in age. You can have embryos that are looking normal, but are genetically abnormal. One other thing that can contribute apart from age is the condition in the laboratory. When the transfer depends on the doctor and the genetic quality also depends on the environment in the laboratory. 
• The other thing to look out for is the lining of the uterus. That is why some clinics do water scans. Where they put water and then do a scan for you to see the lining of the uterus because the regularity of the uterine lining determines success rate. In Nigeria, fibroids are very common and sometimes fibroids make the lining of the uterus become irregular and that affects success rate
• Embryo transfer is also one thing that can contribute to success rate. That is why some clinics do a dummy transfer before they do the real transfer. It is like a practice transfer, where there is no embryo. This helps the doctor know what the uterus looks like, so it can help when he/she wants to do the transfer. And that is why almost everybody now does ultrasound guided embryo transfer. 

When you do IVF, when your lab is working well, about 70 to 75% of your eggs will get fertilized in the laboratory. Fertilization will take place in about 70 to 75% of the eggs. Fertilization is the mixture, or the interchange of genetic material between the sperm and the egg. A lot of errors happen during this process, that is why the success rate of IVF is still less than 50%, despite the fact that about 70 to 75% of eggs get fertilized. The majority of the failure of IVF comes at the stage of implantation. You have your embryos, but they just don’t get attached to the endometrium of the uterus or the lining of the uterus. 

The question everybody is always asking is why is this so? We know very little about implantation. That is why I started with the example of you planting a seed. You don’t plant a seed today and just because you want to know the progress, you can’t go digging it up two days after. That is why we have limited knowledge when it comes to implantation. There is a lot of work being done about it but there are still a lot of things we don’t know. This is why we call implantation, the black box of reproduction. It is a black box because we don’t really know so much about it. Also because that is where the quality control system of the body really acts. We really don’t want to toy with the quality control system in the body so that our babies will continue to be normal babies. 

There are some things we know about implantation. That success rate for implantation is cumulating. When you do 1-2-3 cycles, the chance of implantation increases, actually implantation success is said to be highest in the first three cycles. After that it is not going to be exponential as it was. So the first three cycles are when you stand the best chance of success. IVF is not something that you plan to do only once. If you want to get the best success from IVF, and you are less than 35, plan to do two cycles. If you are more than 35 years old, then plan to do three cycles. That does not mean you cannot succeed with the first cycle. But your chances are best when you are prepared for multiple cycles in IVF. 

Factors That Influence Success Rate in IVF. 

1. Plan to do more than one cycle. If you succeed the first time. Fantastic. 
2. The other thing is the age of the woman. It is very important, I am not saying that the age of the man is not important. Like I said, the older the two of them are, the more the chances of errors when genetic materials are exchanged.
3. The weight of the woman is also very important. If you are overweight, your chances of success are reduced. There is a body mass index where the body mass index is calculated using weight in kilograms over height squared in meters. This is why it is important to lose weight before you do IVF. In some countries where your BMI is higher than 30, you are not even allowed to do IVF. It is known to affect success rate. When you are older, one of the decisions that needs to be made will be the source of eggs. 

There is no difference between IVF babies and normal babies. About 6 million babies all over the world are from IVF. We called them test tube babies initially, but we prefer to call them IVF babies. 

The source of eggs. 

If you are more than 40, your chances are better using donor eggs than using your own eggs. Sometimes you might need to pull your eggs together. That is why it is important that you talk to the doctors who have good experience about this. 

Sperm selection.

Sperm count is not an issue per se, in IVF. Because with technology we can overcome very poor sperm count. But that is not without technology. You have to look at clinics that have the technology that you need, is it ICSI, PICSI, and then sometimes DNA fragmentation testing, which is very important for people who work in petrochemical industries.

Embryo selection. 

The problem with reproduction is really implantation. And the problem with this is because in IVF, about 70 to 75% of the day 3 embryos cannot become babies because there has been a mistake in the exchange of genetic materials between the man and the woman which we call aneuploidy. But with day 5 about 50% of the embryos cannot become babies because of this same reason. The mistaken exchange of genetic materials. The problem with the embryologist is how to pick these embryos that look very normal, but they are genetically abnormal. The problems are in the genes and not in the way they look. Therefore it is only when you do pre implantation genetic screening that you can determine the difference between these two embryos. Which one is normal and which one is not normal. That is usually the dilemma of success. 

One thing people always ask again is that “I want day 5 embryo because its pregnancy rate is better”. That is not true. Pregnancy rate is not necessarily better with day 5 embryos, what day 5 embryo can do for you is that it helps to select normal embryos. I said 70 to 75% of day 3 embryos cannot become babies, but about 50% of day 5 embryos cannot become babies. By the time your embryos reach up to day five, you have less embryos to contend with. And therefore, your choice also becomes much easier, and that is the only thing this does. When you have day 5 embryos, you can transfer less embryos and reduce the risk of multiple pregnancy that accompanies IVF. But you can’t say that the pregnancy rate will be better. It is not everybody that can have day 5 transfer, because it depends on the number of embryos that you have. Some clinics say whatever happens, you must do day 5. But 50% of embryos on day five also are not normal. So I don’t know whether there is any advantage about that. 

The other things to look out for are what ancillary treatments the clinic offers.  Do they have facilities for laser assisted hatching? Do they have facilities for acupuncture? Do they do endometrial scratching etc.

Question And Answer 

1. Question: Will donor eggs help?  

Answer: Yes. It is not everybody who needs donor eggs but if you are more than 40 to 43 years old, you might need to use donor eggs. You will need to do tests first to know what is required from you and what you need to do in order for it to be successful. We want to see how you will be successful, without upsetting you also. 

1. Question: Is your hospital in Abuja, same standard as the one in Lagos?

Answer: Oh, wonderful question. Yes, I can tell you that. All Nordica clinics are the same. What we do is that we rotate our staff around so that we don’t just sit in one place. So it is like, if you want to have a franchise or you want to be successful, then you need to move people around so that we can guarantee that the quality of service you have in one place, is what you are going to have in another place. But there are some things that you might need to tweak, depending on the culture of the people that you are serving, because you don’t want to offend the people you are serving as well. 

1. Question: I have heard about 11 failed IVF which later the woman conceived. How is it possible?

Answer: In medicine, one thing we learnt is that nothing is impossible. We can never say never, and we can never say always. So I don’t know, everything is possible. But we need to have more details to know whether it actually happened or not. 

Conclusion
We have spoken a lot about what contributes to IVF success and how IVF can fail. I would like to conclude by saying that, even though we know that IVF can make the sperm and the egg unite. When IVF first started, it was a nightmare for people who had poor sperm count. The traditional IVF just depended on the sperm being able to fertilize the egg until we started doing ICSI when we could actually inject the sperm into the egg. As IVF can succeed in about 70 to 75% of the time to guarantee fertilization, it cannot guarantee life. 

Life is a different thing. You need implantation before there can be a pregnancy. It is the characteristic of the couple that is first and foremost very important in guaranteeing whether the cycle succeeds or fails. I’m talking about age, weight, and habits like smoking. I’m talking about the vocation you do. Do you work in petrochemicals? Are you a gardener? What is the age of the man himself? And of course, what is the cause of infertility? These are factors that are peculiar to the couple. 

The other thing the couple brings to the table is the quality of the decisions that they make. Is the quality of the decision based on facts? Some couples don’t bother to understand the technology behind IVF. Everybody wants to be pregnant, but you need to know what technology can deliver and what it cannot deliver. So apart from the quality of the decision the couple make, the facilities of the clinic, and the experience of the caregivers are also very important.