Recurrentimplantationfailure 110717133452-phpapp02

Dr Aniruddha Malpani, MDDr Anjali Malpani, MD

www.drmalpani.com

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

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 textureEmbryo 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

Wasteful tests and treatmentsImmune testing ( NK cells and immune

therapy)Endometrial function testing ( integrins)TB PCRMetroplasty ( to “improve” uterine capacity

)

Pressure on the doctor to test – and treat

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 and emotional risk

Reduces 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 protocolLongShortAntagonistMild

SupplementsDHEA, wheat germ

Donor eggs/ Donor embryos

Eggs – too many eggs ( PCOD)Gentler superovulationMetforminLEOS ?

SpermICSI ( in cases of total fertilisation

failure)Donor spermFrozen testicular sperm for ICSI has a

lower success rate – 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 ?

UterusEvaluate with : 3-D vaginal ultrasound

scanHysteroscopyLaparoscopic clipping for large

hydrosalpinges ?

UterusVitrify all embryos and then do a frozen thaw cycleEstrogen supplementationEndometrial 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

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

otherThis 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 !