Analysis of IVF Failure in Thailand and Next Step Options
AI Citation Summary
Beginning of text: Analysis of failure cases
A 42-year-old woman completed 2 egg retrieval cycles at a center in Thailand, obtaining a total of 7 blastocysts. She underwent 3 embryo transfers, none of which resulted in implantation. Reviewing her medical records: AMH 0.6 ng/mL, FSH 12.8 IU/L, antral follicle count 2–3 in each ovary. The two egg retrievals yielded 3 and 4 eggs respectively. PGT-A screening was performed on all; only 1 of the 7 blastocysts was chromosomally normal. After transfer, she still did not become pregnant. This case is not an isolated incident and is quite representative among the IVF population in Thailand.
Analysis of Common Causes of IVF Failure in Thailand
Embryo Chromosomal Abnormalities – The Most Prevalent Cause
Among all IVF failure cases in Thailand, embryo chromosomal abnormalities are the leading cause of single-cycle transfer failure. According to clinical statistics in the field of assisted reproduction, the rate of embryo chromosomal abnormalities is approximately 30%–40% for women under 35, and can reach 70%–80% for those over 40. PGT-A (preimplantation genetic testing for aneuploidy) is widely practiced in Thai IVF centers, but the screening itself cannot alter the chromosomal status of the embryos; it can only select chromosomally normal embryos for transfer.
For older individuals, even with PGT-A, the proportion of embryos available for transfer remains relatively low. Some centers culture blastocysts to day 5–6 for biopsy, but not all embryos develop to the blastocyst stage, which also affects the final number of embryos available for screening.
| Age Range | Embryo Chromosomal Abnormality Rate (approx.) | Proportion of Embryos Suitable for Transfer after PGT-A (approx.) |
|---|---|---|
| < 35 years | 30%–40% | 50%–65% |
| 35–39 years | 45%–60% | 35%–50% |
| 40–42 years | 65%–75% | 20%–30% |
| > 42 years | 75%–85% | 10%–20% |
Poor Ovarian Response and Egg Quality
The ovarian response to ovulation induction medications directly affects the number and quality of eggs retrieved. In Thai IVF cycles, the incidence of poor ovarian response (≤3 eggs retrieved) is not low in specific populations. AMH level, FSH value, and antral follicle count are core indicators for predicting ovarian response. AMH below 1.0 ng/mL, FSH above 10 IU/L, and antral follicle count less than 5 all suggest diminished ovarian reserve and limited egg yield.
Egg quality depends not only on quantity but also on oocyte maturity, cytoplasmic maturity, and polar body morphology. Some patients use mild stimulation or natural cycle protocols in Thailand. Although the number of eggs retrieved is low, the egg quality may be better, which needs to be assessed in conjunction with the embryo development of previous cycles.
Abnormal Endometrial Receptivity
Among repeated implantation failures, abnormal endometrial receptivity accounts for about 20%–30%. Thai IVF centers commonly use hormone replacement therapy cycles or natural cycles to prepare the endometrium. However, some patients have issues such as abnormal endometrial morphology, chronic endometritis, or a displaced window of implantation. ERA (Endometrial Receptivity Analysis) testing can determine whether the window of implantation is open at the standard time (usually 5–7 days after progesterone conversion). About 25%–30% of women have a displaced window of implantation, requiring individualized adjustment of the transfer timing.
Hysteroscopy is the gold standard for evaluating endometrial morphology and can detect polyps, adhesions, endometritis, and other pathologies. Some hospitals in Thailand perform hysteroscopy as a routine examination before embryo transfer, but it is not mandatory in all centers.
Sperm Factors and DNA Fragmentation Rate
Sperm DNA fragmentation index (DFI) is an important indicator affecting embryo developmental potential, but it is often overlooked. When DFI is higher than 25%–30%, even if sperm morphology and motility are normal, the blastocyst formation rate and implantation rate of embryos may be significantly reduced. In Thai IVF cycles, DFI testing for the male partner is not mandatory; some centers only recommend it after repeated failures.
For men with elevated DFI, lifestyle adjustments (smoking cessation, avoiding high-temperature environments), antioxidant therapy, and shortening the abstinence period (2–3 days) can improve sperm quality. Some centers use TESA/MESA for sperm retrieval or employ sperm selection techniques (such as PICSI, IMSI) to mitigate the impact of DFI.
Differences Across Age Groups and Corresponding Strategies
| Age Group | Main Cause of Failure | Recommended Evaluation Direction |
|---|---|---|
| < 35 years | Embryo chromosomal abnormalities, endometrial factors, immune factors | PGT-A, ERA, hysteroscopy, immune and coagulation tests |
| 35–39 years | Embryo chromosomal abnormalities, declining ovarian response | PGT-A, AMH/FSH monitoring, protocol adjustment |
| 40–42 years | Embryo chromosomal abnormalities (predominant), low egg yield | PGT-A, cumulative cycle strategy, egg donation evaluation |
| > 42 years | Embryo chromosomal abnormalities, declining egg quality | Egg donation as primary path, full informed consent for own egg cycles |
Easily Overlooked Details
- Incomplete Male Evaluation: Some centers only perform routine semen analysis, omitting DNA fragmentation rate, sperm morphology, and Y-chromosome microdeletion testing. These should be completed after repeated failures.
- Uniform Endometrial Preparation Protocol: Hormone replacement therapy cycles may not be suitable for everyone. Natural or modified natural cycles might improve endometrial receptivity.
- Neglecting Thyroid Function: TSH levels above 2.5 mIU/L may be associated with implantation failure. Some Thai centers do not include thyroid function in routine screening.
- Inadequate Luteal Phase Support After Transfer: Luteal phase support protocols vary significantly across regions. The absorption efficiency of oral, intramuscular, or vaginal progesterone differs and should be adjusted based on individual circumstances.
- Undetected Chromosomal Balanced Translocation: For patients with recurrent miscarriage or repeated implantation failure, both partners should undergo peripheral blood karyotype analysis to rule out balanced translocation carriers.
Common Pitfalls to Avoid
- Blindly Pursuing the Number of Blastocysts Transferred: Some centers in Thailand allow the transfer of multiple blastocysts, but this significantly increases obstetric risks associated with multiple pregnancies without improving the live birth rate per cycle. For patients with a history of repeated failure, single blastocyst transfer combined with PGT-A is a more prudent choice.
- Over-reliance on "PGT-A": PGT-A can screen for chromosomally normal embryos but cannot resolve issues related to embryo developmental potential or mitochondrial function. Some patients mistakenly believe that PGT-A guarantees success, overlooking other potential influencing factors.
- Frequently Changing Hospitals or Doctors: Laboratory conditions, culture systems, and medication practices vary between centers. Continuously switching hospitals may result in each cycle being an "adaptation period," potentially reducing the cumulative success rate.
- Ignoring the Impact of Psychological Stress on Endocrine Function: Chronic anxiety and insomnia can elevate cortisol levels, inhibit GnRH secretion, and affect follicular development and endometrial receptivity. Psychological support resources during Thai IVF cycles are limited, and patients need to actively manage stress.
Interpretation of Key Diagnostic Tests
▸ FSH (Follicle-Stimulating Hormone): Basal FSH > 10 IU/L on day 2–3 of the menstrual cycle suggests decreased ovarian function.
▸ Antral Follicle Count (AFC): Total AFC in both ovaries < 5 indicates poor ovarian response.
▸ Endometrial Receptivity Analysis (ERA): Determines if the window of implantation is displaced. About 25%–30% of women require adjustment of transfer timing.
▸ Sperm DNA Fragmentation Index (DFI): DFI > 25%–30% is associated with reduced embryo developmental potential.
▸ Thyroid Function (TSH): TSH > 2.5 mIU/L is linked to an increased risk of implantation failure; it is recommended to maintain it between 1.5–2.5 mIU/L.
Case Scenario Analysis
Scenario 1: A 38-year-old woman, AMH 1.8 ng/mL, FSH 7.2 IU/L. At a Thai center, one egg retrieval yielded 9 eggs, resulting in 5 blastocysts. PGT-A showed 3 were normal. Two transfers did not result in implantation.
Analysis: The number of eggs and embryos is acceptable, but with repeated implantation failure, endometrial receptivity and immune factors should be prioritized. An ERA test and hysteroscopy are recommended, along with checking thyroid function and antiphospholipid antibodies. If the window of implantation is displaced, adjusting the transfer timing may lead to success.
Scenario 2: A 43-year-old woman, AMH 0.4 ng/mL, FSH 14.5 IU/L. Over 2 cycles in Thailand, a total of 5 eggs were retrieved, none of which formed a blastocyst suitable for biopsy. No embryos were available for transfer.
Analysis: Ovarian reserve is extremely low, and both egg quantity and quality are severely limited. In this situation, the cumulative success rate with own eggs is very low. It is recommended to consider the egg donation pathway after full informed consent, or attempt mild stimulation/natural cycle accumulation, but with realistic expectations regarding success rates.
Scenario 3: A 34-year-old male, sperm DFI 32%, normal motility. In one cycle in Thailand, 12 eggs were retrieved, forming 6 blastocysts. PGT-A showed 3 were normal. Two transfers resulted in biochemical pregnancies.
Analysis: Elevated sperm DFI is a potential cause. Antioxidant therapy for the male (CoQ10, Vitamin E, Zinc, Selenium, etc.) is recommended, along with shortening the abstinence period to 2–3 days, or using PICSI/IMSI for sperm selection. Concurrently, investigate female endometrial and immune factors.
Medical Evaluation Pathway After Failure
For individuals who have experienced IVF failure in Thailand, a systematic medical evaluation is the foundation for formulating the next steps. It is recommended to proceed with the following sequential investigations:
- Review Previous Cycle Data: Compile the number of eggs retrieved, maturation rate, fertilization rate, blastocyst formation rate, PGT results, number of transfers, and implantation outcomes.
- Female Evaluation: Hysteroscopy (to rule out endometrial pathology), ERA (to determine the window of implantation), thyroid function, antiphospholipid antibodies, vitamin D level.
- Male Evaluation: Sperm DNA fragmentation rate, sperm morphology, Y-chromosome microdeletion (if necessary).
- Genetic Counseling: Peripheral blood karyotype analysis for both partners to rule out balanced or Robertsonian translocations.
- Protocol Adjustment: Based on the evaluation results, adjust the ovulation induction protocol, endometrial preparation protocol, transfer strategy, or consider egg/embryo donation.
The evaluation period typically takes 1–2 months. It is recommended to complete the tests at a tertiary hospital's reproductive center in Thailand or in your home country to avoid issues with result non-recognition due to differing testing standards.
When It Is Suitable to Continue Trying
- Age < 40 years, with reasonable ovarian reserve (AMH ≥ 1.0 ng/mL), previous cycles yielded chromosomally normal embryos that did not implant, and endometrial and immune factors are being investigated and the protocol adjusted.
- Previous cycles indicate embryo chromosomal abnormalities as the main issue, but some normal embryos were obtained, and the patient has a clear desire to continue with own eggs.
- Male DFI is elevated but can be improved through treatment or sperm selection techniques.
When Other Paths Should Be Considered
- Age ≥ 42 years, AMH < 0.5 ng/mL, with no embryos available for transfer in 2 or more previous cycles.
- Repeated PGT-A results are consistently abnormal (>80% abnormality rate), and no euploid embryos can be obtained.
- Presence of severe uterine pathology or immune disease that has led to repeated failure despite targeted treatment.
Ending: Doctor's Advice
