1. Dr Aniruddha Malpani, MD
Dr Anjali Malpani, MD
www.drmalpani.com

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. Patients blame themselves !
Did the IVF cycle fail because I did
something wrong ?
Exercise ? Diet ?
Stress ?
Is my body rejecting the
embryo ?

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. After an IVF failure
Be empathetic
Be honest
Truth with
compassion

6. Analysis
What went right ?
What went wrong ?
What have we learned ?
Do we need to change
anything the next time ?
What do we change ?

7. Troubleshooting
Clinic
Superovulation protocol
Ovarian response
Endometrial thickness and texture
Embryo transfer – technical
difficulty ?

8. Troubleshooting
Lab
Fertilisation rate
Embryo quality
How did other patients on the
same day do ?

9. 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

10. 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

11. 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 !

12. Many tests available
Expensive
Not validated
Often lead to more confusion
Clinical utility not well defined

13. Wasteful tests and
treatments
Immune testing ( NK cells and immune
therapy)
Endometrial function testing ( integrins)
TB PCR
Metroplasty ( to “improve” uterine capacity
)
Pressure on the doctor to test – and treat

14. 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

15. 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 and emotional
risk
Reduces the emotional roller
coaster ride for the patient !
Helps the doctor to learn from
each cycle !

16. What can we change ?
Eggs
Sperm
Uterus
Clinic

17. Eggs - too few eggs ( poor ovarian
response)
Superovulation protocol
Long
Short
Antagonist
Mild
Supplements
DHEA, wheat germ
Donor eggs/ Donor embryos

18. Eggs – too many eggs ( PCOD)
Gentler superovulation
Metformin
LEOS ?

19. Sperm
ICSI ( in cases of total fertilisation
failure)
Donor sperm
Frozen testicular sperm for ICSI has a
lower success rate – it’s best to use
fresh testicular sperm

20. Difficult embryo transfer ?
Under general anesthesia ?
Under ultrasound guidance ?
Change the catheter set ?
Consider doing a ZIFT ?

21. Uterus
Evaluate with : 3-D vaginal ultrasound
scan
Hysteroscopy
Laparoscopic clipping for large
hydrosalpinges ?

22. Uterus
Vitrify all embryos and then do a frozen thaw cycle
Estrogen supplementation
Endometrial injury to induce improve blood flow
Intrauterine perfusion of GCSF ( granulocyte colony
stimulating factor)
Surrogacy

23. Clinic
Refer the patient to another clinic
Can be helpful – second opinion, with a
different perspective !

24. 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

25. 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

26. 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 !

27. 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 !