“Medicine is a humbling profession.” I must have heard that once, but I can’t remember where. Just a single line dropped nonchalantly somewhere along the way of 11 years of postgraduate medical education. At the time it was one of those things you hear, know is important and profound, but won’t be able to fully appreciate for many years. Maybe it was the curmudgeonly, bearded psychiatrist during medical school after failing to convince a judge that a psychotic patient should be committed in Kings County Hospital’s 
infamous “G Building.” Or the seasoned surgeon after managing a rare complication to a procedure he had safely performed thousands of times. Just when things appear to be figured out, on auto-pilot, medicine reminds you and humbles you.
As a field, reproductive medicine is witnessing unprecedented success. Refinements in extended embryo culture and molecular genetics enable single embryo transfer (SET) delivery rates to exceed 60%. More than 60% of transfers at Reproductive Medicine Associates of New Jersey include only one embryo, dramatically increased from less than 10% just a few years ago. The paradigm of synchronous, euploid blastocyst transfer is promoted [1] and lauded with a cover story in a national OB/GYN publication[2]. But then medicine reminds and humbles you.
A couple who you fear is taking too high of a risk of twins by transferring two euploid blastocysts is devastated with a negative pregnancy test. A woman who thought she could never conceive short of IVF gets pregnant naturally just days before the planned start of her IVF cycle. You feel genuine relief for her only to find weeks later that the pregnancy has Down syndrome. After failing to achieve a pregnancy in 3 prior IVF cycles at another clinic, your patient gets discharged to her obstetrician with a perfectly normal-appearing pregnancy after euploid SET. Then she learns of a life-threatening (non-genetic) birth defect on ultrasound.
For each story like the ones above there are at least 100 happy stories of ongoing pregnancies and term deliveries. But it’s these stories that push us to get even better. In research meetings we often talk about the “other 40 percent” – those high-quality, chromosomally normal blastocysts that for some inexplicable reason don’t implant and make babies. We still have lots to learn and improve about uterine receptivity, ovarian stimulation, in vitro culture conditions, and embryo transfer technique. Anything that can chip away at that other 40 percent will help.
Just as soon as you were humbled things start to turn – a patient has one egg retrieved and it develops into a normal blastocyst and healthy pregnancy. Another patient with low ovarian reserve barely produces enough follicles to make an egg retrieval beneficial, yet she winds up having several, high- quality blastocysts develop. The pendulum always seems to swing back in the right direction.
References:
[1] Scott RT Jr., Franasiak JM, Forman EJ. Comprehensive chromosome screening with synchronous blastocysts transfer: time for a paradigm shift. Fertil Steril [E-pub] http://www.fertstert.org/article/S0015-0282(14)00568-8/pdf
[2] Forman EJ, Scott RT Jr. Euploid Single-Embryo Transfer: The New IVF Paradigm. Contemporary OB/GYN. 2014 July;59(7): 18. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/euploid-single-embryo-transfer-new-ivf-paradigm?page=full
Blog post by Dr. Eric J. Forman, MD, FACOG
Reproductive Medicine Associates of New Jersey
Morristown, NJ
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