Recurrent implantation failure

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Why IVF cycles fail - and how we can prevent IVF failure

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Recurrent implantation failure

  1. 1. Dr Aniruddha Malpani, MD Dr Anjali Malpani, MD www.drmalpani.com
  2. 2. Doctor, why did my IVF cycle fail ? <ul><li>IVF failure causes a lot of distress </li></ul><ul><li>Both for patient and doctor </li></ul><ul><li>Lots of questions </li></ul><ul><li>No clear answers </li></ul>
  3. 3. Patients blame themselves ! <ul><li>Did the IVF cycle fail because I did something wrong ? </li></ul><ul><li>Exercise ? Diet ? </li></ul><ul><li>Stress ? </li></ul><ul><li>Is my body rejecting the embryo ? </li></ul>
  4. 4. Please do not shun your patient <ul><li>After an IVF failure, patients are very vulnerable </li></ul><ul><li>Can be angry with the doctor </li></ul><ul><li>Blame you for the failure </li></ul><ul><li>Doctors do not want to talk to patients when the cycle fails </li></ul><ul><li>Please do not abandon your patient ! They need you the most at this time ! </li></ul>
  5. 5. After an IVF failure <ul><li>Be empathetic </li></ul><ul><li>Be honest </li></ul><ul><li>Truth with compassion </li></ul>
  6. 6. Analysis <ul><li>What went right ? </li></ul><ul><li>What went wrong ? </li></ul><ul><li>What have we learned ? </li></ul><ul><li>Do we need to change anything the next time ? </li></ul><ul><li>What do we change ? </li></ul>
  7. 7. Troubleshooting <ul><li>Clinic </li></ul><ul><ul><li>Superovulation protocol </li></ul></ul><ul><ul><li>Ovarian response </li></ul></ul><ul><ul><li>Endometrial thickness and texture </li></ul></ul><ul><ul><li>Embryo transfer – technical difficulty ? </li></ul></ul>
  8. 8. Troubleshooting <ul><li>Lab </li></ul><ul><ul><li>Fertilisation rate </li></ul></ul><ul><ul><li>Embryo quality </li></ul></ul><ul><ul><li>How did other patients on the same day do ? </li></ul></ul>
  9. 9. Good quality embryos ? <ul><li>The only good embryo is the one which becomes a baby ! </li></ul><ul><li>We can grade embryos, but we still cannot predict which embryo will become a baby ! </li></ul><ul><li>Blastocyst/ laser hatch/ coculture </li></ul><ul><li>Newer tools - Embryo – “omics” </li></ul><ul><li>PGD – Array CGH – better genetic technology </li></ul>
  10. 10. Good quality embryos ? <ul><li>Please give photos of the embryos to the patient </li></ul><ul><li>Every patient should insist on these photos </li></ul><ul><li>Documentary evidence of the quality of treatment received </li></ul>
  11. 11. Best to tell the truth ! <ul><li>Often, the truthful answer is – we do not know why the cycle failed. </li></ul><ul><li>Human reproduction is not an efficient enterprise </li></ul><ul><li>Not an answer patients want to hear </li></ul><ul><li>Not an answer doctors want to give </li></ul><ul><li>Tend to overtest - and this leads to overtreatment ! </li></ul>
  12. 12. Many tests available <ul><li>Expensive </li></ul><ul><li>Not validated </li></ul><ul><li>Often lead to more confusion </li></ul><ul><li>Clinical utility not well defined </li></ul>
  13. 13. Wasteful tests and treatments <ul><li>Immune testing ( NK cells and immune therapy) </li></ul><ul><li>Endometrial function testing ( integrins) </li></ul><ul><li>TB PCR </li></ul><ul><li>Metroplasty ( to “improve” uterine capacity ) </li></ul><ul><li>Pressure on the doctor to test – and treat </li></ul>
  14. 14. These tests are not helpful ! <ul><li>Please set realistic expectations for your patients before the cycle starts </li></ul><ul><li>Prepare them for failure ! </li></ul><ul><li>Often, just need to be patient to achieve success </li></ul>
  15. 15. Guaranteed pregnancy programs <ul><li>Help to reduce patient anxiety. The patient knows that the doctor’s interests and the patient’s interests are aligned </li></ul><ul><li>Reduces financial and emotional risk </li></ul><ul><li>Reduces the emotional roller coaster ride for the patient ! </li></ul><ul><li>Helps the doctor to learn from each cycle ! </li></ul>
  16. 16. What can we change ? <ul><li>Eggs </li></ul><ul><li>Sperm </li></ul><ul><li>Uterus </li></ul><ul><li>Clinic </li></ul>
  17. 17. Eggs - too few eggs ( poor ovarian response) <ul><ul><li>Superovulation protocol </li></ul></ul><ul><ul><ul><li>Long </li></ul></ul></ul><ul><ul><ul><li>Short </li></ul></ul></ul><ul><ul><ul><li>Antagonist </li></ul></ul></ul><ul><ul><ul><li>Mild </li></ul></ul></ul><ul><ul><li>Supplements </li></ul></ul><ul><ul><ul><li>DHEA, wheat germ </li></ul></ul></ul><ul><ul><li>Donor eggs/ Donor embryos </li></ul></ul>
  18. 18. Eggs – too many eggs ( PCOD) <ul><li>Gentler superovulation </li></ul><ul><li>Metformin </li></ul><ul><li>LEOS ? </li></ul>
  19. 19. Sperm <ul><li>ICSI ( in cases of total fertilisation failure) </li></ul><ul><li>Donor sperm </li></ul><ul><li>Frozen testicular sperm for ICSI has a lower success rate – it’s best to use fresh testicular sperm </li></ul>
  20. 20. Difficult embryo transfer ? <ul><li>Under general anesthesia ? </li></ul><ul><li>Under ultrasound guidance ? </li></ul><ul><li>Change the catheter set ? </li></ul><ul><li>Consider doing a ZIFT ? </li></ul>
  21. 21. Uterus <ul><li>Evaluate with : 3-D vaginal ultrasound scan </li></ul><ul><li>Hysteroscopy </li></ul><ul><li>Laparoscopic clipping for large hydrosalpinges ? </li></ul>
  22. 22. Uterus <ul><li>Vitrify all embryos and then do a frozen thaw cycle </li></ul><ul><li>Estrogen supplementation </li></ul><ul><li>Endometrial injury to induce improve blood flow </li></ul><ul><li>Intrauterine perfusion of GCSF ( granulocyte colony stimulating factor) </li></ul><ul><li>Surrogacy </li></ul>
  23. 23. Clinic <ul><li>Refer the patient to another clinic </li></ul><ul><li>Can be helpful – second opinion, with a different perspective ! </li></ul>
  24. 24. Information Therapy <ul><li>Need to counsel and educate your patients prior to start of the IVF cycle </li></ul><ul><li>Prepare for Plan B ! </li></ul><ul><li>IVF can be a roller coaster ride </li></ul><ul><li>Patients need to have realistic expectations ! This will help both you and the patient cope better with failure, when this occurs </li></ul>
  25. 25. Be kind ! <ul><li>Your patients are very emotionally vulnerable at this time </li></ul><ul><li>IVF is often their last hope </li></ul><ul><li>When this fails, it’s the last straw </li></ul><ul><li>They feel they are useless ; that their body is “rejecting “ the embryo; and that they will never be able to have a baby </li></ul><ul><li>Help them cope with this rough patch </li></ul>
  26. 26. Support Groups <ul><li>Peer support can be very helpful </li></ul><ul><li>Encourage patients to talk to each other </li></ul><ul><li>This can be therapeutic </li></ul><ul><li>Expert patients can help the others ! </li></ul>
  27. 27. Serenity Prayer <ul><li>God grant me the serenity to accept the things I cannot change; </li></ul><ul><li>The courage to change the things I can; </li></ul><ul><li>And the wisdom to know the difference. </li></ul><ul><li>Useful prayer – for both patients and doctors ! </li></ul>

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