" We are making babies, not cookies"

An honest interview with Dr Rahi Victory from Victory Reproductive Care, about the importance of a personalised approach in Assisted Reproduction.

Should anyone be given a chance to Assisted reproduction regardless of their circumstances? Are supplements and diet any good? How often should we change protocols? Is a personalized approach better? What to look for, when we are looking for an RE?

Q: Trying to conceive. For how long should we try on our own, before seeking help?

Dr Victory: This is dependent on age and menstrual regularity. If your periods are irregular you should seek assistance immediately. This is typically because of PCOS. Patients with PCOS have substantially higher risks of uterine cancer due to irregularity and chances of conception are extremely low. These patients need help immediately.

For patients with regular cycles, they should follow the following guidelines:

< 35 years of age – try for one year then seek help

35– 40 years of age. – try for six months then seek help

>40 – try for three months then seek help

Q: How old is realistically too old, with own eggs, in Assisted Reproduction? At which point does it become a waste of time and money?

Dr Victory: This is a great question but difficult to answer because it really depends on a number of factors, including age, BMI, social habits, AFC, AMH. So for example, if the patient is 43 but has an AFC of 20, and an AMH of 20 pmol/l (2.5 ng/ml) then she still has a decent chance. But on average after the age of 40 chances of success are less than 25% in most centers and continue to decline rapidly to the point where they are negligible after 43.

There is some complicated chronologically backwards math, but it essentially goes like this:

A) 60% of euploid blastocysts will adhere and survive in utero

B) 60% of mature fertilized oocytes will reach blastocyst stage

C) 90% of oocytes can be fertilized with advanced ICSI

D) At age 43, 90% of oocytes are genetically abnormal (probably 75%- 80% at age 40)

E) So if you do the math you need close to 40 eggs to get one pregnancy on average.

Most patients can’t make 40 eggs at the age of 40.

Obviously the math is just math and you could make a normal embryo on first try, but based on averages it would be very difficult…

Q: Do you have cut-offs for AMH, AFC or FSH? Or do you believe everyone should be given a chance, regardless of their ovarian reserve, yet up to a certain age?

Dr Victory: I believe that everyone should be given a choice regardless of their circumstances. However, I think they need to be told honestly what those chances actually are in clear terms so they’re not just paying for something without knowing what they’re actually getting out of it.

So if you know your chances are 5% and you still want to go ahead, that’s fine. But if you think that your chance is 30% and it’s actually 5% that is dishonest on the part of the physician.

Q: Do you believe the term “geriatric” should apply to a woman over 40 trying to conceive? Many clinics employ this term.

Dr Victory: Lol. I have a post on this! I hate the term geriatric pregnancy. Risks for pregnancy don’t increase till after the age of 40. The term geriatric specifically applies to women over the age of 65. The only risks of pregnancy for older women include hypertension and diabetes, and we can minimize these with careful diet and use of aspirin. There are fetal risks of autism, cerebral palsy and these are real and unavoidable. And of course there are genetic risks for the fetus starting with a 50% risk of miscarriage and then significant risks of genetic anomalies in the fetus. Again, if the woman knows the risks and she’s willing to proceed it’s fine. There is no reason to call women geriatric. I find it extremely demeaning, disrespectful and erroneous.

Q: One of your mottos is “we are making babies, not cookies”. How important is the personalized approach in IVF treatments.

Dr Victory: I believe that there is a basic starting point for everyone, but care needs to be individualized because everyone’s biology is different. A woman with a high AMH and AFC can be treated with a standard approach. But a woman with the same AMH and AFC with endometriosis needs a totally different approach including lower dosing, interval Lupron and letrozole, and supplements to reduce inflammation. One simple change, but two wildly different approaches. So yes, we’re making babies, not cookies!

Q: Do you believe it is important to change protocols in case of a previous failed cycle?

Dr Victory: I think it’s critical we learn from every cycle. Many centers just keep doing the same thing over and over again. That is useless. If you did really well, but then had a miscarriage, a repeat cycle may be ok. But if you did poorly, or if there was no pregnancy, then it’s imperative we reanalyse from the beginning. We need to make sure that we are always making progress. There is always room for improvement. Doing the same thing multiple times is a great way to make money, and a terrible way to achieve success.

Q: How important is it for infertility patients to be educated about their situation? Could this help them in making the right choices?

Dr Victory: I think it is absolutely imperative that patients be educated. This is of course dependent on the ability of the patient to understand the concepts. But everyone needs to understand all of the aspects of their diagnosis, all of the options available for treatment (not just IVF), the rationale for the treatments being proposed, the costs and of course, most importantly, the outcomes that are expected.

Q: Most patients have a very hard time saying “no” to their REs, even when they are uncomfortable with the suggested approaches or with the outcome of a failed cycle. Should they advocate for themselves, or should they just go with the flow?

Dr Victory: So this is where I differ from almost everyone else. I DON’T believe that patients should have to advocate for themselves. If the patients need to advocate for themselves, then the RE has not done their job. I did four years of medical school, five years of residency, three years of REI fellowship, and I read five to seven journals every month, attend conferences, and constantly look for new information in every place I can. How can a patient with none of that experience even know that they should advocate for themselves? If we are truly being “healers” then it’s our job to provide patients with answers so that they’re saying yes because they understand and want to, not because we’ve told them to.

Q: First time infertility patients often feel pressured into doing IVF. With insurance sometimes not covering the costs, financial strain adds to the frustration of not being able to procreate. Except for situations in which IVF is clearly the only choice (same sex couples, severe male infertility, tubal issues) do you believe other approaches may be worth exploring?

Dr Victory: I always offer patients all options that are applicable. I never push patients into anything and no one should. My conversation generally goes along the lines of the following: “You could do nothing. This has a reasonable chance, but admittedly it is very low. You probably wouldn’t be here if you wanted to do nothing. You could try natural approaches including seeing our naturopath, using vitamins, correcting bad social habits (e.g. smoking, drinking, drug use), and/or having more sexual intercourse (or sometime less…). These have a chance of x % per month. You could take medications either oral or injectable to increase the number of eggs you produce on a monthly basis with a y % chance of success. You can do insemination with either natural egg production, oral medications or injectable for increasing chances to z% chance of success. Or you could do IVF with or without your own eggs/sperm for the highest chances. Here is how much each of them costs… here is what you can expect to experience from each choice. Here is what I would recommend in your case…”

At that point I usually offer what is genuinely best for each patient. We almost always advocate for something other than IVF, unless age or ovarian reserve are concerns.

Q: Scientific methods put aside, are there really any other ways we can improve our chances of getting pregnant? And by this I mean nutrition, acupuncture, supplements, relaxation techniques.

Dr Victory: Absolutely. We have a naturopath on staff, and I encourage use of natural supplements, inositol, NAC, curcumin extract, acupuncture, weight loss, Mediterranean diet, prayer, exercise, melatonin, and many others. I strongly encourage all of these. For example, where some women with PCOS are frequently told to just go lose weight, I always tell them there are three facets to management: medication, supplements, and healthy eating and exercise. I tell them all: “You can’t just do one, but actually have to do them all”

Q: Do you believe that older women, with very limited ovarian reserve, may still have a chance of getting pregnant naturally when assisted reproduction failed them?

Dr Victory: For sure. If assisted reproduction fails them, natural attempts for some time are particularly reasonable as the next step is egg donation anyways and this is not time sensitive. However, it’s completely up to the patient. Some want to proceed because the failure is too painful to endure, while others benefit from some time off. It’s part of the discussion. We have an incredible program of resources including a psychologist, social worker, naturopath, family physician and a free online program to help our patients navigate the psychological burden of their journey.

Q: Big renowned clinic with amazing success rates, or smaller one with individualized approach? And why?

Dr Victory: Wow! That’s a great question. I think a renowned clinic with amazing success should only get there by having an individualized approach. That’s who we are!

Q: What makes Victory Reproduction Care stand out and how come you have so many patients travelling even from abroad, considering you are based in a small Canadian town?

Dr Victory: I think it’s because I’m honest, I’m engaged, I spend the time personally with all my patients, and I don’t see patients as dollar signs. I see them as people who need my help. I take my role as a physician with religious seriousness. I feel I’ve been given a gift in becoming a doctor. The gift comes with a cost: I’m responsible for the lives put in my care. And that is the highest responsibility anyone can ever take upon themselves. So I give it 150% every day.

Q: If there were one thing you could tell an infertile couple seeking help, what would it be?

Dr Victory: I’m here for you!

You can follow Dr Victory on his Instagram account @rahivictory.md or on his YouTube channel at www.youtube.com/drvictory

N.B This is neither paid advertisement, nor is the author receiving any referral incentives from Victory Reproductive Care.