Failed IVF - what next ?

When your IVF cycle fails, it's often hard to bounce back. Even though your head understands that IVF doesn't have a 100% success rate, it's hard to deal with the failure. In their heart of hearts, every patient who starts an IVF cycle believes that this cycle is going to work ! ( If they didn't, it'd be very difficult to even start the cycle ).

When the cycle fails, your hopes go crashing down, and it is difficult to pick up the pieces and carry on living. This is why it's important to give yourself some time ; grieve; and then bounce back. Rather than get stuck with thinking about if onlys and blaming yourself for the failure, you need to use an analytical framework, so you know what to do next.

Most patients get stuck in the phase of asking questions to analyse the failure. Doctors, did I do something wrong ? Did the embryos fail to implant because I did not rest ? Did the doctor do something wrong. Patients are often desperate, and will spend hours scouring the internet, to try to find answers to their questions.

Actually, these are very unproductive questions. The quality of answers does depend upon the quality of questions; and rather than ask - What went wrong ? or Why did the embryos not implant ? a far more useful question would be - What can we learn from this failed cycle ? And based on this additional hard-earned information, what can we do differently the next time to increase our chances of success.

If it's been a perfect cycle ( Grade A embryos; trilaminar endometrium of more than 8 mm; and an easy transfer), then often all one needs to do is to repeat it until it works. This requires a lot of patience and fortitude, but human reproduction is not an efficient enterprise, and you don't have a better alternative except to pray and try again.

What are some of the things which you can change for the next treatment cycle ?

If the follicles did not grow properly, or the ovarian response was poor ( or exaggerated because of PCOD), you can tweak the superovulation protocol. Experienced doctors are quite good at doing this, so that they can help you grow more eggs, of better quality, based on studying your earlier response. Thus, if you are a poor ovarian responder, they can increase your dose of HMG for superovulation; or use the Letrozole Anatgon protocol.

Your second option is to change your doctor. If you have lost confidence in your doctor; or if you find that after the failure, your doctor is not being open or transparent and is not providing satisfactory answers, it's always a good idea to get a second opinion, to confirm you are on the right track ! It's important that you have a detailed treatment summary of your IVF cycle, including photos of your embryos, so an IVF specialist can provide intelligent advise.

What are the other things over which you have control, and which you can change ?

You can use donor sperm, but with the availability of ICSI, the need to do this is practically zero today. In fact, we use donor sperm only for men with complete testicular failure. While some clinics will blame the poor quality of sperm for a failed ICSI cycle ( by claiming the sperm have high DNA fragmentation or abnormal DNA or abnormal morphology or very poor motility), none of these are issues which adversely impact ICSI fertilization rates in a good IVF lab. No matter how poor the sperm motility or how abnormal their shape or their DNA, in a good IVF lab, fertilization after ICSI is pretty much guaranteed ! Also, once the sperm have fertilized the egg, their task is accomplished. This may not seem intuitive, but boor quality sperm are usually never responsible for poor quality embryos, because embryo cleavage is dependent upon the energy provided by the mitochondria in the egg cytoplasm - not the sperm !

For a large number of patients with poor ovarian reserve, donor eggs is often the best option to maximize success rates. While this is a fairly straightforward solution, this can be psychologically extremely difficult to come to terms with, especially for young women.

Many women will want to change the uterus when they encounter repeated IVF failure. They believe that their uterus is abnormal, and is "rejecting" their embryos. This reasoning seems logical, but is actually flawed, because the uterus is usually just a passive recipient, and surrogacy does not help to improve pregnancy rates if the woman's uterus is normal.

The trouble is that after a failed IVF cycle, patients want a scientific explanation as to why the cycle failed. They are not happy when the doctor tells them the truth - that it was random bad luck. They demand a diagnosis, because they believe that the doctor needs to accurately "diagnose" the problem, in order to find the right solution. Doctors are happy to trot out a glib diagnosis of "failed implantation" to keep their patients happy - and many will then order a battery of expensive tests to " pinpoint " the cause.

However, "failed implantation " is just a waste paper basket diagnosis, which doesn't provide any useful information. It's just a meaningless label which only describes what happened - that the embryos did not implant, that's all. Unfortunately, when a cycle fails, it's hard to think logically. Patients demand testing, and doctors order these to keep their patients happy.

This wastes a lot of time, money and energy. Even worse, the results of some of these tests come back as abnormal. These are just false positives, which have no clinical importance, but once a result is abnormal, the doctor is then obliged to "treat " it. This wastes even more time and money for the poor patient !

Think about it rationally for a minute. If these tests were really useful, then why would a doctor wait for the IVF cycle to fail before ordering the test ? He would order them before starting the first IVF cycle, if they did in fact provide any useful information.

If your IVF cycle has failed, it's important that you have good-quality documentation of your IVF cycle ( including photos of your embryos ), so that you can get an intelligent second opinion to make sure you're on the right track !

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.