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

Published in: Health & Medicine, Technology
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  • dr malpani written very good guide for ivf treatmen.
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Managing IVF failure - a guide for the doctor

  1. 1. Dr Aniruddha Malpani, MD Dr Anjali Malpani, MD
  2. 2. 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
  3. 3. Patients blame themselves ! Did the IVF cycle fail because I did something wrong ? Exercise ? Diet ? Stress ? Is my body rejecting the embryo ?
  4. 4. 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 !
  5. 5. After an IVF failure Be empathetic Be honest Truth with compassion
  6. 6. 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 !
  7. 7. Analysis What went right ? What went wrong ? What have we learned ? Do we need to change anything the next time ? What do we change ?
  8. 8. Troubleshooting Clinic Superovulation protocol Ovarian response Endometrial thickness and texture Embryo transfer – technical difficulty ?
  9. 9. Troubleshooting Lab Fertilisation rate Embryo quality How did other patients on the same day do ?
  10. 10. 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
  11. 11. 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
  12. 12. 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 !
  13. 13. Many tests available Expensive Not validated Often lead to more confusion Clinical utility not well defined
  14. 14. 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
  15. 15. 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
  16. 16. 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 !
  17. 17. What can we change ? Eggs Sperm Uterus Clinic
  18. 18. 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
  19. 19. Eggs – too many eggs ( PCOD) Gentler superovulation Metformin Myoinositol LEOS ?
  20. 20. Sperm ICSI ( in cases of total fertilisation failure , when IVF was done)
  21. 21. 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
  22. 22. 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
  23. 23. Difficult embryo transfer ? Under general anesthesia ? Under ultrasound guidance ? Change the catheter set ? Consider doing a ZIFT ?
  24. 24. Uterus Vaginal ultrasound scan to evaluate uterine lining Hysteroscopy should be used very sparingly. Most probably will be normal if ultrasound scan is normal
  25. 25. 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
  26. 26. Clinic Refer the patient to another clinic Can be helpful – second opinion, with a different perspective !
  27. 27. 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
  28. 28. Free app for IVF patients
  29. 29. 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
  30. 30. 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 !
  31. 31. 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 !
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