What should you do after a failed IVF cycle?
There are too many doctors who are very paternalistic, and they just tell you, you need IVF, and they don’t explain your odds of success or what the entire process is going to be like. So, for the most part, when we talk about failed cycles, we usually mean not getting pregnant. But when it comes to IVF, it can also mean maybe not making embryos or not having any normal embryos. So when we think through it, let’s break down a couple things. So for IUI, right, IUI is intrauterine insemination.
This is when you’re taking sperm and you’re putting it into the uterus instead of having it in the vagina where it normally is. Now, of course, the vagina is an acidic environment, and so the sperm is in this ejaculate in order to protect it. And so you do have a concentrated sample, and moving it into the uterus can help some people get pregnant.
IUI, even when you combine it with medications to improve or to increase someone’s ovulation, is not going to help somebody ever get pregnant over their age-related chance. So whatever your age-related chance is, that’s your maximum chance of success with ovulation induction and or ovulation induction IUI. So when it comes to a failed cycle, most of the time we mean we did the cycle and we didn’t get pregnant.
However, sometimes it can mean, like if you’re doing ovulation induction, that you didn’t respond right, and so you failed it because you didn’t respond. So I always counsel people, goal one is to have an appropriate response to the medication in our goal range, whether that’s one to two, one to three, one to four, two to four, whatever our goal number of eggs is to make with the medications that you’re achieving that. That alone might be a successful cycle.
Now, if you don’t get pregnant, well, if you’re age 37, you’re not going to have a higher than a 10 to 12% chance of it working. And so the most probable outcome was that the IUI did not work. And if you’re upset because the cycle failed, part of making sure it is framed right is, well, that was the most probable outcome.
That’s why often people need multiple IUIs and that it’s more successful for people who are younger because their age-related chance of getting pregnant. So to me, the IUI didn’t necessarily fail. If you responded appropriately, the sperm went good.
You just didn’t get pregnant. That was an expected outcome. And understanding how many you’re going to do and your chance of success is very important.
More often we’re talking about IVF, right? And IVF is very complicated. So for the vast majority of people, IVF is now done in two parts. So we think of IVF or in vitro fertilisation in general, we’re taking one month’s group of eggs, getting them to grow, taking those eggs out of the body, fertilising them in the lab, growing out to embryos and freezing the embryos.
We may or may not be doing genetic testing. Then we are doing a frozen embryo transfer, which is where we take one of the embryos, thaw it, put it in a catheter and put it into the body at the appropriate time. Sometimes these can be done together and that’s considered a fresh transfer where you get the eggs out, fertilise them, let them grow out, take the best one or two and put them in the body and freeze the rest.
Although we are seeing less and less that being done as first-line treatment because you can’t do genetic testing. It has a higher risk of ovarian hyperstimulation. The uterine lining may be less receptive when there’s high oestrogen or progesterone receptors.
And so this is becoming less common practise, although not unheard of. But for me, it is the rare candidate who is young enough to not need genetic testing, but a low egg count, so they’re not going to hyperstim who fits these criteria.
So let’s look at IVF. Well, IVF then, if we consider it growing eggs and making embryos and doing genetic testing, you can fail at multiple places. You could not respond appropriately to the stimulation meds or have enough mature eggs. Maybe there’s not good fertilisation. Maybe the embryo stopped developing and you don’t make any embryos. Maybe they do, but you don’t have any genetically normal.
Now your doctor should talk you through all steps of this process. So you should understand what is expected. And very commonly, I will see somebody who’s older, who is just so upset.
At places such as Medline Academics, the idea of redefining “failure” in the context of fertility treatment becomes an integral part of the educational curriculum for doctors. With a focus on structured Fellowship in IVF and Reproductive Medicine, IVF, and andrology, Medline Academics places emphasis on the need to understand expected as well as unexpected outcomes of treatment, optimization of protocols, lab-to-clinic correlation, etc., to make the fertility expert more adept at evaluating whether the failure of the treatment was within the expected spectrum of results or not.
They didn’t get any normal embryos yet. That was the most probable scenario. So let’s pretend you’re 40 and you have an antral follicle count of eight and we get eight mature eggs, which is wonderful.
And then you have 75 to 80% of them fertilised. So that’s six. And then you have half of them grow out to blastocysts. These are average numbers. So that would be three. And then if you do genetic testing, I would expect 20 to 25% be normal.
What is 20 to 25% of three? Zero to one. So you have zero normal embryos. That is exactly what would be expected.
Even if you hit perfect on the other metrics, that doesn’t mean you can’t find a normal embryo, but I would counsel that patient. You are going to need multiple cycles. So we’re not going to consider this a failure.
If those are the numbers we have, we did great. We got the right number of mature eggs. They did good in the lab. We just didn’t have a normal one in there. And that’s appropriate because of our age. On the flip end, I will see patients have terrible cycles and nobody’s even told them that in my mind, it’s a failure because they didn’t achieve this outcome.
Maybe they were well under-stimulated, didn’t get as many mature eggs, had a bad protocol. Therefore, they resulted in a much lower number than they should have had based on their age and their follicle count because of the protocol that was selected. And that may result in them having a lower number of embryos and a smaller family size.
And they may need another cycle for that. And then you have frozen embryo transfers, which for the most part, failure is inability to get pregnant or you have negative pregnancy tests, but it can also mean not responding right to the protocol, not having a lining that looks good, needing to cancel the cycle.
Whatever the cycle was, where did we fall at above or below average? Where can we make room for improvement? What can I do better? Should I do a different protocol? How many were mature? Do you need a longer trigger? Do they need to get to a bigger size? What showed in the lab? How was our sperm or egg quality? Maybe should we need to improve any of that or was it exactly as we expected? And we need to do it again.
At Dr. Kamini Rao Hospitals, failed cycles are an opportunity for clinical insight and not endpoints. The treatment in this IVF hospital in Bangalore, undergoes critical review to understand what is expected, where one went wrong in achieving optimization, and what should be the personalized future protocols to make certain that evidence-based care is imparted with clarity of communication and emotional support.
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