"Not Suitable For Transfer"

Perhaps the most dramatic moment during an in vitro fertilization (IVF) cycle occurs just prior to the embryo transfer (the placement of embryo(s) into the uterus). Patients are shown pictures of their embryos and asked to decide which and how many embryos to transfer (within acceptable guidelines). We describe the quality of each embryo and provide them with our recommendations to assist them in their decision. Patients understand how significant this decision is and will frequently agonize for long periods of time before making a final decision.

Several years ago, very soon after I began my practice, I had an experience that profoundly affected the way I approach this situation.

At that point in my career, I had little experience with the laboratory aspects of IVF, and so I relied heavily on the opinions of my embryologists when discussing embryos with patients. We had planned to do a frozen embryo transfer for a patient that particular afternoon, but late in the morning I received bad news. Only two of six embryos had survived the thaw and their quality was dismally poor. Written by an embryologist on a yellow sticky note attached to the picture of these embryos were just four words: "Not Suitable For Transfer."

I called the wife and gave her the bad news along with our recommendation not to proceed with the transfer, and she tearfully agreed. About an hour later, I received a call from the husband asking me if he could come late that afternoon to discuss the situation, and I agreed to stay after our usual closing time to see him. By the time he arrived, alone, the office and laboratory staff had left for the day. I showed him the embryos, explained that they were very slow growing and were "D" grade, the lowest grade an embryo can get and still be alive (an "A" grade is best). The chance of a healthy live birth with those embryos was probably well below 5%, I told him. He paused, looked directly at me and said, "You know, I'm having a crisis in confidence here. In our fresh cycle, we transferred excellent embryos and did not get a pregnancy. And now we have virtually nothing to transfer in our frozen cycle." I just nodded, because, frankly, I was having a bit of a crisis in confidence too.

He lowered his head and cradled his forehead in one of his hands clutching an eyebrow between his thumb and ring finger, "My wife is devastated. What should we do?" For what seemed like a very long time, we just sat there, the picture of the embryos on the desk between us. I remember the office being so quiet. I remember it seeming like the air was completely still, and I remember the sun succumbing to the night and falling helplessly below a mountain outside the window. It felt like the universe realized something momentous was about to happen and had no choice but to stop and hold its breath while awaiting this decision.

And suddenly the decision wasn't so difficult anymore. As I looked at those embryos, I realized we were having a crisis in confidence in them, and we had given them no opportunity to prove themselves. I realized that we had flinched in the face of fear rather than confronting it with hope. I told him, "We don't know how low the chance of a success is if we do a transfer, but we can be certain that if we don't do a transfer the chance of success can only be one thing: zero."

He and his wife decided to go forward with the transfer.

And so I called the clinical and laboratory staff back in--you can imagine how excited they were to return to do a "hopeless case." He went to pick his wife up and we did the transfer. Twelve days later, the miraculous happened and she became pregnant, but we remained guarded given the appearance of the embryos. Every ultrasound was an ordeal as we worried about a miscarriage or an abnormal fetus. But the fetus, completely oblivious to our anxieties, grew and developed until it was delivered as a healthy full-term boy, who they chose to name "Sam," my very favorite name for some reason.

For years they have sent me regular updates and pictures of Sam which I treasure. A couple of weeks ago I talked to his father on the phone and he told me Sam was going away to college, that he was athletically and intellectually gifted, but most importantly, that he was a caring, compassionate person who frequently did volunteer work, a person always focusing on what he could do for others. And as I heard the pride and love in his father's voice, a tear slowly made its way down my right cheek as I remembered that very still night when we chose to believe that a fear of failure should never be chosen over a hope for success.

Without hope, my patients would have never met and been able to love and be loved by their wonderful son. There would have been no Sam, a young man with an unlimited potential to bring happiness and goodness into the many lives he will touch in his life.

I think about him every time I sit across the table from a devastated couple looking hopelessly at a picture of embryos that, at first glance, seem "not suitable for transfer."