Please remember that pregnancy rates with IVF/ICSI are in the range of 40-50% per
cycle. After making provisions for early or late miscarriages, pregnancy losses,
ectopic pregnancies, the net live birth rate is in the range of 40% per cycle. This
means that 60% of treatments would fail.
Our chief staff is constantly updated on the lines of ESHRE and ASRM recommendations
to ensure that the patients get only the best of medical care and technology.
Only recently, the clinic switched to a “freeze-all” policy for a huge segment of
patients (indications given in section on embryo freezing) after a meticulous application
of embryo Vitrification techniques and research on endometrial receptivity. It is
now proven that a lot of patients have failed IVF attempts with fresh embryo transfer
because the endometrium was not in a receptive state during the stimulation cycle.
With better Vitirication techniques there is no damage to frozen embryos. Focus
has now shifted to optimizing the endometrial receptivity prior to embryo transfer
and this can only be achieved in frozen embryo transfer cycles. Take home baby rates
improved by 15% (50% as against 35% in 2013) with adoption of this newer approach.
With the “freeze all” strategy, we are able to achieve success in many patients
who had failed previously owing to age, abnormal estradiol and progesterone levels
during the stimulation cycle, endometriosis, polycystic ovaries, ovarian hyper-stimulation,
poor response, thin endometrium and unexplained implantation failure. The clinic
has been having consistently high success rates with frozen embryo transfer (in
the range of 50-60%).
Other common causes of failure are:
-
Suboptimal sperm quality (especially
ICSI patients with sperm problems)
-
Suboptimal egg quality (patients
> 35 years of age or low AMH levels, Polycystic ovaries and endometriosis)
-
Thin lining of the uterus (endometrium)
or insufficient blood supply in the uterus.
-
Hormonal imbalances created by
the injections given to produce good eggs which might put the uterus out of phase
for receiving the embryo.
-
Improper response of the ovaries
to the ovarian stimulation protocol used (short antagonist or long agonist).
-
Most importantly, the CHANCE (only
50% at best) per cycle. This implies that even if all goes well, failure might be
unexplained and implies the necessity for more cycles or attempts.
Measures might be suggested
-
Repeat cycle,
maybe with a change in dosage or protocol.
-
Embryo freezing
(all embryos) especially in patients with early miscarriages, low amh, less embryos,
thin endometrium or too many eggs (hyperstimulation.
-
Higher dose of
injections (FSH) to get more eggs and embryos (for freezing)
-
Use of endometrial scratching
or intrauterine instillation of G-CSF to improve the receptivity of the uterus and
implantation chances.
-
Use of donor eggs
(in case of repeated failures owing to poor egg quality).
-
Use of donor sperm
(in case of repeated failures of ICSI).
-
Use of donor embryos
(in case of both eggs and sperms being of poor quality OR when cost is an issue)
-
Use of surrogacy (repeated unexplained
or explained implantation failures owing to poor endometrium or problems in the
uterus).
A complete trial of IVF usually entails 3-5 cycles of IVF. All the transfers done
from one egg retrieval constitute one completed cycle. It is important for the couple
to understand this so as to avoid emotional breakdowns during treatment.
Patients are often concerned about the stage of the embryo at the time of transfer.
In our experience, day 3 and day 5 (blastocysts) give equivalent success rates so
it is not advisable to do blastocyst transfers at the very outset. Also, recent
research shows that pregnancy rates in some categories of patients would be lower
with blastocyst transfers. This decision is best left to your doctor and his embryologist.
There are also reports of a higher incidence of monozygotic twinning with blastocyst
transfer.
There are suggestions that Preimplantation genetic testing (PGT) and diagnosis (PGD)
might benefit patients with repeated IVF failures but this is still in a grey area
as far as international consensus is concerned. As of now PGT is best restricted
to patients of advanced age (if doing iVF using own eggs), those with recurrent
miscarriages or those with inheritable disease that needs to be ruled out at the
embryo stage. PGT helps to eliminate miscarriages by diagnosing genetically abnormal
embryos but does not improve the overall pregnancy or live birth rates.
Also, newer techniques such as time lapse imaging, IMSI (Intracytoplasmic morphologically
selected sperm injections), assisted hatching and metabolonomics are still in the
research phase and their absolute utility towards increasing success rates is yet
to be established. So also, tests for endometrial receptivity (ERA) are at the moment
invasive and the results only give a rough guide to the implantation window. We
are awaiting a non-invasive ERA test wherein an embryo transfer could be done in
the same cycle as the test (and not in a subsequent month).