Recurrent IVF failure can be devastating for patients and challenging for their doctors. Several tests have been proposed to help identify the causes of embryo implantation failure, and possibly increase the likelihood of achieving a successful pregnancy.
WHY DOES IVF FAIL
One needs to understand that IVF is not a treatment of illness. It is the process of forming new life. That's why it has a limited success rate which varies from 40 to 50% in less than 35 years of age and changes with age and various reasons of infertility.
But majorly there are 4 causes of IVF failure
1. embryonic
2. endometrium
3. body environment
4. lab selection
Embryonic causes can be majorly because of three reasons
1. Problem in egg
2. Problem in sperm
3. Problem in lab
Which Tests Can Help Identify the Cause of My IVF Implantation Failure?
Uterine Evaluation/Hysterosalpingogram (HSG)
Sperm DNA Fragmentation Test
Endometrial Receptivity Assay (ERA)
Preimplantation Genetic Testing for Aneuploidy (PGT-A)
Immunologic Tests
Problem in eggs can be because of either endometriosis, poor ovarian reserve, premature ovarian failure or, severe PCOD. Problem in sperm can be because of severe reduced sperm count or motility or abnormal sperm or absent sperms. The lab conditions have to be ideal such as multiple good quality incubators, high quality air which requires a constantly running Air Handling Unit, multiple laminar flow with HEPA filters, high quality good culture media and disposables and high quality human skills and stringent quality control and quality assurance systems(QC & QA).The process of embryo formation is very much dependent on a good lab quality. All our units have very high-quality lab equipment.
Endometrial problems may be because of intrauterine polyps, intrauterine submucous fibroids, endometrial infection (chlamydia, streptococci, staphylococci, tuberculosis), low levels of Lactobacilli in the endometrium, thick endometrial hyperplasia, out of phase endometrium, non-receptive endometrium and thin endometrium. Thin endometrium is an intrinsic problems which can be because of intrauterine adhesions due to infections like tuberculosis , previous miscarriages or previous intrauterine surgical procedures like D&C
Extrinsic problem other than the uterus like hydrosalpinx of tubes , fibroids which are big in size, big cysts in ovaries as well as medical conditions like hypertension, diabetes mellitus ,thyroid or hyperprolactinemia ,etc and autoimmune problem like APLA,, LA ,,ACA, Thrombophilia’s and immunological problems like increase in natural killer cells can also lead to implantation failures.
In patients with repeated IVF failures , after taking detailed history , we normally would do an 3-D three dimensional ultrasound in these patients . If ultrasound shows any abnormalities like fibroids or hydrosalpinx, we would correct them with laparoscopic cum hysteroscopic surgery. In such operated patients we will perform IVF after 3 to 6 months of surgery. In case there is no abnormality, we would go for ICSI immediately. Normally we would perform an ICSI cycle and freeze the embryos at the 8-cell stage on day 3. We will culture the embryos in embryoscope if available . If the embryos are less in number, we would perform repeated cycles and freeze good number of embryos, with the process of embryo pooling. Normally the embryos are frozen by the technique of vitrification. In patients with low counts, poor motility or poor morphology, prior to ICSI we would select sperms using microfluidics or picsi or imsi. In patients with severe OAT with repeated failures and high sperm DNA fragmentation index > 30 %, we would do a TESA or a TESE and extract sperms directly from the testis and perform ICSI. After this we would perform diagnostic sos operative hysteroscopy in the month prior to the cycle in which we plan to do the embryo transfer. This hysteroscopy would also cause endometrial scratching, which is known to increase chances of pregnancy. However, we perform endometrial scratching with pipelle in those patients in whom we do not do hysteroscopy. In the frozen thaw cycle, we give oestradiol valerate tablets to grow the endometrium to > 9 mm. If the endometrial growth is not adequate and is < 7 mm we would instil intrauterine G CSF or PRP to grow the endometrium. Sometimes we may instil GCSF or PRP in patients with endometrium > 9mm, in order to improve their chances of pregnancy. However this is debatable , and patients will be adequately counselled, prior to the procedure. When the endometrium is > 7-9mm, triple line with good blood flow, we will start progesterone and thaw the embryos on Day three after starting progesterone. We will do sequential transfer or Blastocyst transfer. Prior to the transfer we perform Assisted laser hatching to increase the implantation of the embryo. Nowadays we are also offering pre implantation genetictesting or Non invasive chromosomal screening of Blastocyst prior to transfer in such patients. We supplement the luteal phase with progesterone and estrogen (sometimes). We also occasionally use adjuvants such as oral aspirin, low molecular weight heparin SC, vaginal/oral sildenafil, oral steroids and intravenous intralipids, especially when we suspect immunological problems.This is done after proper counselling of the patient. Our unit is one of the leading IVF units in the country and the world who can achieve high success rates with patients having repeated IVF failures.
Pre-natal sex selection and sex determination is illegal in India and not done here. It is a punishable offence.