Managing IVF failure - a guide for the doctor

Dr Aniruddha Malpani, MDDr Anjali Malpani, MD

www.drmalpani.com

Doctor, why did my IVF cycle fail ?IVF failure causes a lot of distress

Both for patient and doctorLots of questionsNo clear answers

Patients blame themselves !Did the IVF cycle fail because I did

something wrong ?Exercise ? Diet ?Stress ?Is my body rejecting the

embryo ?

Please do not shun your patientAfter an IVF failure, patients are

very vulnerableCan be angry with the doctorBlame you for the failureDoctors do not want to talk to

patients when the cycle failsPlease do not abandon your patient !

They need you the most at this time !

After an IVF failureBe empatheticBe honest Truth with compassion

The role of the gynecologistYou are the patient’s primary care

doctor Can counsel them Have a very important role to play !Review the IVF medical records

with the patientCheck embryo photos !

AnalysisWhat went right ?What went wrong ?What have we learned ?Do we need to change

anything the next time ?What do we change ?

Troubleshooting

Clinic Superovulation protocolOvarian responseEndometrial thickness and texture

Embryo transfer – technical difficulty ?

Troubleshooting

LabFertilisation rateEmbryo qualityHow did other patients on the same day do ?

Good quality embryos ?The only good embryo is the one which

becomes a baby !We can grade embryos, but we still

cannot predict which embryo will become a baby !

Blastocyst/ laser hatch/ cocultureNewer tools - Embryo – “omics”PGD – Array CGH – better genetic

technology

Good quality embryos ?Please give photos of the embryos to

the patientEvery patient should insist on these

photosDocumentary evidence of

the quality of treatment received

Best to tell the truth !Often, the truthful answer is – we do

not know why the cycle failed. Human reproduction is not an

efficient enterpriseNot an answer patients want to hearNot an answer doctors want to give Tend to overtest - and this leads to

overtreatment !

Many tests availableExpensiveNot validatedOften lead to more confusionClinical utility not well defined

Pressure on the doctor to test – and treatEndometrial function testing ( integrins)Endometrial receptivity assay ( ERA)TB PCRImmune testing ( NK cells and immune

therapy)Sperm DNA fragmentationMetroplasty ( to “improve” uterine

capacity

These tests are not helpful !Please set realistic expectations for your

patients before the cycle startsPrepare them for failure !Often, just need to be patient to achieve

success

Guaranteed pregnancy programsHelp to reduce patient anxiety. The

patient knows that the doctor’s interests and the patient’s interests are aligned

Reduces financial riskReduces the emotional roller

coaster ride for the patient !Helps the doctor to learn from

each cycle !

What can we change ?EggsSperm UterusClinic

Eggs - too few eggs ( poor ovarian response)

Superovulation protocolLong, Short, AntagonistAggressive - Letrozole with HMGMild ( mini-stimulation)

SupplementsDHEA, wheat germ, others

Donor eggs/ Donor embryos

Eggs – too many eggs ( PCOD)Gentler superovulationMetforminMyoinositolLEOS ?

SpermICSI ( in cases of total fertilisation failure , when IVF was done)

SpermTeratozoospermia is only very very rarely a cause of fertilisation failure after ICSI ( globozoospermia)

Abnormal sperm do not cause abnormal embryos !

Sperm FISH and sperm DNA fragmentation tests are of no use

SpermFrozen testicular sperm for ICSI has a lower success rate because many of these sperm are immotile. It’s best to use fresh testicular sperm

Difficult embryo transfer ?Under general anesthesia ?Under ultrasound guidance ?Change the catheter set ?Consider doing a ZIFT ?

UterusVaginal ultrasound scan to evaluate uterine lining

Hysteroscopy should be used very sparingly. Most probably will be normal if ultrasound scan is normal

Thin uterine liningVitrify all embryos and then do a

frozen thaw cycleEstrogenEndometrial injury to induce improve

blood flowIntrauterine perfusion of GCSF

( granulocyte colony stimulating factor)Surrogacy

ClinicRefer the patient to another clinicCan be helpful – second opinion,

with a different perspective !

Information TherapyNeed to counsel and educate your

patients prior to start of the IVF cyclePrepare for Plan B ! IVF can be a roller coaster ride Patients need to have realistic

expectations ! This will help both you and the patient cope better with failure, when this occurs

Free app for IVF patientswww.myfertilitydiary.com

Be kind !Your patients are very emotionally

vulnerable at this timeIVF is often their last hopeWhen this fails, it’s the last strawThey feel they are useless ; that their

body is “rejecting “ the embryo; and that they will never be able to have a baby

Help them cope with this rough patch

Support GroupsPeer support can be very helpfulEncourage patients to talk to each other

This can be therapeuticExpert patients can help the others !

Serenity Prayer God grant me the serenity to accept

the things I cannot change;The courage to change the things I can;And the wisdom to know the difference.

Useful prayer – for both patients and doctors !