Very likely this will be a viable pregnancy (probably—80%+).

Good luck!

Geoffrey Sher

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Each and every patient/couple, in undergoing IVF makes huge emotional, physical and (in most cases) also financial investment. The fact that receiving the result of the blood human chorionic gonadotropin (hCG) pregnancy test represents the first decisive hurdle that must be confronted makes this a very big deal The few days after the embryo transfer, waiting for this first outcome report is usually anxiety ridden and highly stressful.  It is thus imperative that the IVF physician and his/her staff deal delicately with the transfer of this critical information. Dropping the ball at this time would be unconscionable. The physician and staff must make themselves accessible to the patient/couple and effect the conveyance of results promptly, professionally and with sensitivity.

At least 2 beta hCG blood tests are done (2-4 days apart). The reporting of pregnancy test results is invariably best deferred until after the 2^nd blood test results are in. This is because an initial equivocal (or even negative) result can correct itself and also, a strongly positive result can become negative by the second test. Sometimes (albeit rarely) a normal embryo will be slow to implant and the hCG level can be <5IU/ml. It can even be undetectable at first. Thus, regardless of the initial blood hCG level, this test should be repeated two days later in order to see if there has been an appreciable rise in hCG since the first test. A significant rise (about a doubling of the initial value) usually suggests that an embryo is implanting and is a prognostic indication of a possible pregnancy. Thus by waiting to report the results until the 2^nd test result is in, will in most cases avoid conveying false hope and/or disappointment.

It is important to bear in mind that beta hCG blood levels do not double every 2 days throughout pregnancy. In fact once the levels start to rise above 4,000U they tend to increase more slowly.

Since (with the notable exceptions of IVF using an egg donor and the transfer of genetically (CGH) tested “competent” embryos, the likelihood of a successful IVF outcome will (in younger women) at best be 50-55% (at best), it is important to counsel patients in advance of the need to have rational expectations. It is equally important to inform patients exactly how, when and by whom they will receive the news and thereupon, in the event of a “negative outcome” when and by whom they will be counseled.

As soon as an embryo begins to implant and its root system (trophoblast) comes into contact with endometrial tissue, the embryo starts to release the pregnancy hormone, hCG in to the woman’s blood stream. About 12 days after egg retrieval, 9 days after a day 3 embryo transfer and 7 days after a blastocyst transfer the woman should have a quantitative beta hCG blood pregnancy test performed. By that time almost all hCG injected to prepare the developing eggs for egg retrieval, there should be minimal hCG left in the woman’s blood stream. Thus the detection of >5 IU of hCG per ml of blood tested is an indication that the embryo tried to implant.

Since with Third party-IVF (i.e. Ovum donation, gestational surrogacy, embryo adoption or frozen embryo transfers-FET) no hCG “trigger is administered, the detection of any amount of hCG in the blood is regarded as significant.

What is Considered Slow Rising hCG Levels?

Often times an initial rise in hCG (between the 1^st and 2^nd test) will be slow (failure to double every 48 hours). When this happens, a 3^rd and sometimes even a 4^th hCG test should be done at 2 day intervals. A failure to double on the 3^rd and/or 4^th test is a poor prognostic sign. It usually indicates a failed or “dysfunctional implantation but in some cases a progressively slow rising hCG level might point to a tubal (ectopic pregnancy. Diagnosis requires additional serial blood hCG testing, ultrasound examinations and clinical follow-up to detect any symptoms or signs of an ectopic pregnancy.

In some cases the 1^st beta hCG level starts high (well over 20IU/ml) and then drops with the 2^nd test, only to start doubling once again thereafter. This sometimes suggests that there were initially more than one embryos implanting and that one of these subsequently succumbed and one survived to continue a healthy implantation.

It is customary for the IVF clinic staff to call the patient/couple and the referring physician with the results of the hCG pregnancy test. Often times, the IVF physician or nurse‑coordinator will work through the referring physician to arrange for the all pregnancy tests. . If the patient/ couple wishes to make their own arrangements, the program should give them detailed instructions about the necessary tests.

If the two blood pregnancy tests indicate that one or more embryos are implanting, some programs advocate daily injections of progesterone or the use of vaginal hormone suppositories for several weeks to support the implanting embryo(s). Others, including our own, give hCG injections three times a week for several weeks until the pregnancy can be defined by ultrasound. Some IVF programs do not prescribe any hormones at all after the transfer.

Patients with hCG levels that show the appropriate doubling 2 day doubling following FET or third‑party parenting through IVF surrogacy or ovum donation will receive estradiol and progesterone injections, often in conjunction with vaginal hormone suppositories, for 10 weeks following the diagnosis of implantation by blood pregnancy testing.

Although a positive Beta hCG blood pregnancy test indicates the possibility of a conception, pregnancy cannot be confirmed until it can be defined by ultrasound. Until then it is referred to as a “chemical pregnancy). Only once ultrasound examination can confirm the existence of a gestational sac, clinical examination can establish the presence of a viable pregnancy or following abortion, products of conception can be recognized, is it referred to as a clinical intrauterine pregnancy. A strongly positive beta hCG blood level in association with an inability beyond 5 weeks gestation to detect a gestational sac inside the uterus by ultrasound examination is suggestive of an ectopic (tubal) pregnancy The chance of miscarriage progressively decreases from the point of diagnosing a viable clinical pregnancy (a conceptus that has a regular heart beat of between 110 and 180 beats per minute). From this point onwards the risk of miscarriage is usually <15% in women under 39 years of age and less than 35% in women in their early forties.

Dealing with an IVF success is easy…. Everyone feels elated and vindicated. It is dealing with  unsuccessful cases that offer the real challenge. In this regard, nothing is more important than establishing rational expectations from the get go. In some cases (fortunately rarely), the patient/couple will crack under the emotional pressure and will need referral for counseling and in some cases psychiatric therapy.

I always counsel my patients that optimal care does not necessarily equate with an optimal outcome. There are too many variables that are outside of our control…especially the “divine” one. Having been involved in this field for about 30 years, it is my fervent belief that when it comes to IVF, the adage…”man proposes while G-d disposes is always applicable!

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) “

http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

        2. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

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