Managing IVF failure - a guide for the doctor
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Transcript of Managing IVF failure - a guide for the doctor
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
The role of the gynecologistYou are the patient’s primary care
doctor Can counsel them Have a very important role to play !Review the IVF medical records
with the patientCheck embryo photos !
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
Pressure on the doctor to test – and treatEndometrial function testing ( integrins)Endometrial receptivity assay ( ERA)TB PCRImmune testing ( NK cells and immune
therapy)Sperm DNA fragmentationMetroplasty ( to “improve” uterine
capacity
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 riskReduces 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 protocolLong, Short, AntagonistAggressive - Letrozole with HMGMild ( mini-stimulation)
SupplementsDHEA, wheat germ, others
Donor eggs/ Donor embryos
Eggs – too many eggs ( PCOD)Gentler superovulationMetforminMyoinositolLEOS ?
SpermICSI ( in cases of total fertilisation failure , when IVF was done)
SpermTeratozoospermia is only very very rarely a cause of fertilisation failure after ICSI ( globozoospermia)
Abnormal sperm do not cause abnormal embryos !
Sperm FISH and sperm DNA fragmentation tests are of no use
SpermFrozen testicular sperm for ICSI has a lower success rate because many of these sperm are immotile. 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 ?
UterusVaginal ultrasound scan to evaluate uterine lining
Hysteroscopy should be used very sparingly. Most probably will be normal if ultrasound scan is normal
Thin uterine liningVitrify all embryos and then do a
frozen thaw cycleEstrogenEndometrial 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
Free app for IVF patientswww.myfertilitydiary.com
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 !