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Failed IVF Patients

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).

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