Managing IVF failure - a guide for the doctor
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Managing IVF failure - a guide for the doctor

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IVF failure can be heartbreaking for both patients and doctors. This presentation discusses what you can learn from a failed IVF cycle, to maximise chances of success in the next IVF cycle

IVF failure can be heartbreaking for both patients and doctors. This presentation discusses what you can learn from a failed IVF cycle, to maximise chances of success in the next IVF cycle

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Managing IVF failure - a guide for the doctor Managing IVF failure - a guide for the doctor Presentation Transcript

  • Dr Aniruddha Malpani, MD Dr Anjali Malpani, MD www.drmalpani.com
  • Doctor, why did my IVF cycle fail ? IVF failure causes a lot of distress Both for patient and doctor Lots of questions No 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 patient After an IVF failure, patients are very vulnerable Can be angry with the doctor Blame you for the failure Doctors do not want to talk to patients when the cycle fails Please do not abandon your patient ! They need you the most at this time !
  • After an IVF failure Be empathetic Be honest Truth with compassion
  • The role of the gynecologist You are the patient’s primary care doctor Can counsel them Have a very important role to play ! Review the IVF medical records with the patient Check embryo photos !
  • Analysis What 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 protocol Ovarian response Endometrial thickness and texture Embryo transfer – technical difficulty ?
  • Troubleshooting Lab Fertilisation rate Embryo quality How 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/ coculture Newer tools - Embryo – “omics” PGD – Array CGH – better genetic technology
  • Good quality embryos ? Please give photos of the embryos to the patient Every patient should insist on these photos Documentary 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 enterprise Not an answer patients want to hear Not an answer doctors want to give Tend to overtest - and this leads to overtreatment !
  • Many tests available Expensive Not validated Often lead to more confusion Clinical utility not well defined
  • Pressure on the doctor to test – and treat Endometrial function testing ( integrins) Endometrial receptivity assay ( ERA) TB PCR Immune testing ( NK cells and immune therapy) Sperm DNA fragmentation Metroplasty ( to “improve” uterine capacity
  • These tests are not helpful ! Please set realistic expectations for your patients before the cycle starts Prepare them for failure ! Often, just need to be patient to achieve success
  • Guaranteed pregnancy programs Help to reduce patient anxiety. The patient knows that the doctor’s interests and the patient’s interests are aligned Reduces financial risk Reduces the emotional roller coaster ride for the patient ! Helps the doctor to learn from each cycle !
  • What can we change ? Eggs Sperm Uterus Clinic
  • Eggs - too few eggs ( poor ovarian response) Superovulation protocol Long, Short, Antagonist Aggressive - Letrozole with HMG Mild ( mini-stimulation) Supplements DHEA, wheat germ, others Donor eggs/ Donor embryos
  • Eggs – too many eggs ( PCOD) Gentler superovulation Metformin Myoinositol LEOS ?
  • Sperm ICSI ( in cases of total fertilisation failure , when IVF was done)
  • Sperm Teratozoospermia 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
  • Sperm Frozen 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 ?
  • Uterus Vaginal ultrasound scan to evaluate uterine lining Hysteroscopy should be used very sparingly. Most probably will be normal if ultrasound scan is normal
  • Thin uterine lining Vitrify all embryos and then do a frozen thaw cycle Estrogen Endometrial injury to induce improve blood flow Intrauterine perfusion of GCSF ( granulocyte colony stimulating factor) Surrogacy
  • Clinic Refer the patient to another clinic Can be helpful – second opinion, with a different perspective !
  • Information Therapy Need to counsel and educate your patients prior to start of the IVF cycle Prepare 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 patients www.myfertilitydiary.com
  • Be kind ! Your patients are very emotionally vulnerable at this time IVF is often their last hope When this fails, it’s the last straw They 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 Groups Peer support can be very helpful Encourage patients to talk to each other This can be therapeutic Expert 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 !