Dr Aniruddha Malpani, MD
Dr Anjali Malpani, MD
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 ?
Is my body rejecting the
Please do not shun your patient
After an IVF failure, patients are very
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
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
Check embryo photos !
What went right ?
What went wrong ?
What have we learned ?
Do we need to change
anything the next time ?
What do we change ?
Endometrial thickness and texture
Embryo transfer – technical
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
Good quality embryos ?
Please give photos of the embryos to the
Every patient should insist on these photos
Documentary evidence of
the quality of treatment
Best to tell the truth !
Often, the truthful answer is – we do not
know why the cycle failed.
Human reproduction is not an efficient
Not an answer patients want to hear
Not an answer doctors want to give
Tend to overtest - and this leads to
Many tests available
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)
Immune testing ( NK cells and immune
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 – too many eggs ( PCOD)
ICSI ( in cases of total fertilisation
failure , when IVF was done)
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
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 ?
Vaginal ultrasound scan to evaluate
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
Endometrial injury to induce improve
Intrauterine perfusion of GCSF
( granulocyte colony stimulating factor)
Refer the patient to another clinic
Can be helpful – second opinion, with a
different perspective !
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
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
Peer support can be very helpful
Encourage patients to talk to each
This can be therapeutic
Expert patients can help the others !
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