recurrent implantation failure

Dr Aniruddha Malpani, MDDr Anjali Malpani, MD

www.drmalpani.com

Doctor, why did my IVF cycle fail ?IVF failure causes a lot of distress

Both for patient and doctorLots of questionsNo clear answers

Patients blame themselves !Did the IVF cycle fail because I did

something wrong ?Exercise ? Diet ?Stress ?Is my body rejecting the

embryo ?

Please do not shun your patientAfter an IVF failure, patients are

very vulnerableCan be angry with the doctorBlame you for the failureDoctors do not want to talk to

patients when the cycle failsPlease do not abandon your patient !

They need you the most at this time !

After an IVF failureBe empatheticBe honest Truth with compassion

AnalysisWhat went right ?What went wrong ?What have we learned ?Do we need to change

anything the next time ?What do we change ?

Troubleshooting

Clinic Superovulation protocolOvarian responseEndometrial thickness and texture

Embryo transfer – technical difficulty ?

Troubleshooting

LabFertilisation rateEmbryo qualityHow 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/ cocultureNewer tools - Embryo – “omics”PGD – Array CGH – better genetic

technology

Good quality embryos ?Please give photos of the embryos to

the patientEvery patient should insist on these

photosDocumentary evidence of

the quality of treatment received

Best to tell the truth !Often, the truthful answer is – we do

not know why the cycle failed. Human reproduction is not an

efficient enterpriseNot an answer patients want to hearNot an answer doctors want to give Tend to overtest - and this leads to

overtreatment !

Many tests availableExpensiveNot validatedOften lead to more confusionClinical utility not well defined

Wasteful tests and treatmentsImmune testing ( NK cells and immune

therapy)Endometrial function testing ( integrins)TB PCRMetroplasty ( to “improve” uterine

capacity )

Pressure on the doctor to test – and treat

These tests are not helpful !Please set realistic expectations for your

patients before the cycle startsPrepare them for failure !Often, just need to be patient to achieve

success

Guaranteed pregnancy programsHelp 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 !

What can we change ?EggsSperm UterusClinic

Eggs - too few eggs ( poor ovarian response)

Superovulation protocolLongShortAntagonistMild

SupplementsDHEA, wheat germ

Donor eggs/ Donor embryos

Eggs – too many eggs ( PCOD)Gentler superovulationMetforminLEOS ?

SpermICSI ( in cases of total fertilisation failure)

Donor spermFrozen testicular sperm for ICSI has a lower success rate – 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 ?

UterusEvaluate with : 3-D vaginal ultrasound scan

HysteroscopyLaparoscopic clipping for large hydrosalpinges ?

UterusVitrify all embryos and then do a frozen thaw

cycleEstrogen supplementationEndometrial injury to induce improve blood

flowIntrauterine perfusion of GCSF ( granulocyte

colony stimulating factor)Surrogacy

ClinicRefer the patient to another clinicCan be helpful – second opinion,

with a different perspective !

Information TherapyNeed to counsel and educate your

patients prior to start of the IVF cyclePrepare 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

Be kind !Your patients are very emotionally

vulnerable at this timeIVF is often their last hopeWhen this fails, it’s the last strawThey 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

Support GroupsPeer support can be very helpfulEncourage patients to talk to each other

This can be therapeuticExpert patients can help the others !

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 !