The document discusses reasons for IVF failure and provides advice for doctors on supporting patients after a failed cycle. It recommends that doctors be empathetic, honest but compassionate with patients. It also suggests analyzing what went right/wrong with the cycle and considering changes to the protocol, lab techniques, embryo quality checks or referring patients to another clinic for the next attempt. The document emphasizes setting realistic expectations and preparing patients for potential failure to help both patients and doctors cope better.

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 !