Q. I am having IVF failure even though there are good stimulation and embryo production. Why?

Answered by
Dr. Sameer Kumar
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Dec 19, 2018

Hello doctor,

Repeated IVF failure. I would just like an independent opinion, I am 34 years old and already had four failed IVF's. Not once was there a positive pregnancy test. I am healthy, gave birth to a healthy baby boy eight years back with my first husband who sadly passed on a few years ago. Remarried a few years later and have been struggling with infertility. Have been on numerous Clomid and IUI cycles with no success. Finally resorted to IVF and thought that after at least three attempts it would be successful as I had a good response to stimulation and good embryo production. The only issue was my husband's sperm morphology and viscosity. Fertilization was done via ICSI and was told that the blastocyst was top grade and perfect looking and already hatching. Is there any reason why the embryos are failing to implant. I am so frustrated, confused and depressed. The whole experience is emotionally and financially draining especially because I have no issues with my uterus, no hormonal issues, etc. My husband blames me, according to him, if the embryos were perfect looking than the problem surely is me. My clinic said I should come in and try again, however, I do not want to try again not knowing what the problem is or what can be done differently.



Welcome to

I completely empathize with you and understand your concerns here. The primary step where, in your case, things could have gone wrong is the stage of implantation over a non-receptive endometrium of the uterus when a top grade blastocyst is being transferred and each time there is a negative result. The implantation at endometrium is the issue in your case, most likely.

Few things are important for a good endometrium. The endometrial thickness should be more than 9 mm at ET. Good endometrial blood flow in zone 2, 3 and 4 to check for receptivity through transvaginal Doppler study in the mid-cycle before embryo transfer. Before even contemplating IVF, an endometrial biopsy for histopathology report should be obtained to rule out any pre-existent endometritis or and acid-fast bacillus (tuberculous cause). The malefactor is taken care of by ICSI and IVF and hence a high-grade blastocyst is being achieved for transfer. I would like you to share with me the last IVF cycle medicinal protocol, scans, follicular monitoring reports and if possible reports of endometrial biopsy for a histopathology, pap smear report, high vaginal swab culture (if any) for further study and check to ascertain what went wrong in your case.

Thank you doctor,

I do not have any reports with me as it is all kept in the file at the fertility clinic. The protocol for the last transfer which was a frozen embryo transfer was Estinyl from day 1 to day 13. One tablet a day from day 1 to 27, then two tablets a day from day 8 to 12 and three tablets a day from day 26 to 30. Continued with three tablets a day up until the negative result yesterday. Crinone 8 % from day 13 up to yesterday. Prednisone a, as well as a blood thinner, was also taken up until yesterday. Four days before the embryo transfer, an ultrasound was done and the doctor said the lining looked great 8 mm). The only results I have is from the doctor who referred me to the fertility specialist. I have attached the results. Would you recommend a laparoscopy? I am so anxious to try again next month knowing that nothing different has been done.



Welcome back to

I am not so sure with the suitability of the protocol followed for frozen embryo transfer as ethinylestradiol (Estinyl) was seemingly used in excess as compared to progesterone alone, get (Crinone 8 %) which would not have allowed the endometrium to transit to the secretory phase of cycle and mature and become ready for implantation.

The endometrial thickness was less than 9 mm, and ideally, Estradiol levels should be more than 150 pg/ml and progesterone levels should be more than 15mg/ml on a day prior to the frozen-thawed embryo transfer. Progesterone dosage is to be increased from 50 mg/mL to 75 mg/mL if serum progesterone was below 15 ng/mL, and Estradiol dosage is to be increased by 2 mg oral Estradiol and/or the addition of vaginal Estradiol if serum Estradiol was below 150 ng/mL. So this is an important step. I hope you had some records. Also, this is the day when endometrial doppler study should be performed to check for endometrial receptivity as I mentioned earlier. Prednisolone and Aspirin can be started together as an anti-inflammatory and improve thinning of blood, respectively.

From your pap smear report it was evident that you did not have any cervicitis or inflammation of cervix but you have been or were suffering from bacterial vaginosis and candida infection then which if not treated by a seven days course antibiotics and antifungals before contemplating embryo transfer, then there are all chances of iatrogenic insertion of infection into the uterine cavity and infecting the endometrium causing endometritis which under inflammatory effect would render the endometrium. Non-receptive to a transferred embryo. I hope you understand what I am hinting at here. Once I reinstate the need for an endometrial biopsy report for histopathology before contemplating the next IVF cycle.

If there was no issue found in you with regards to menstrual irregularity and that you were ovulating regularly, then I feel there was no apparent need of undertaking an IVF cycle. Your husband with oligoteratoasthenozoospermia can be easily treated with antioxidants and sperm energizers for a period of three months (life-span of sperm is four months) and then after treating your local vaginal infection, I feel you should try naturally for two cycles post his treatment.

But most importantly with a history of multiple IUI earlier, with persistent vaginal bacterial and candida infection, raises suspicion over increased chances of endometritis. So please take a break for a month with natural cycle and get a mid-cycle endometrial biopsy study done after a high vaginal swab culture, ruling out any infection first and then avoiding intercourse till endometrial biopsy day. (This cycle would go waste though, but will help your body to recover from hormonal imbalance following IVF cycles). Also, if you have your earlier reports, ultrasound, HSG reports, hormonal profile, AMH levels, they would be helpful to guide you further.

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