Clinical Judgement in Fertility Treatment: How Dr. Vani Decides

Clinical judgement is what separates one fertility clinic from another. Most pages
explain what a treatment is; this one explains how we decide. These ten questions
have no single textbook answer, they are the clinical judgement calls that differ
from clinic to clinic. Below are mine, as I actually practise them at Jananam
Fertility Centre in Chennai.

At what point do you move a patient from IUI to IVF?

We usually move from IUI to IVF after 3–4 well-timed IUI cycles, but the
decision is never based on cycle number alone. The woman’s age, ovarian reserve, duration
of infertility and underlying diagnosis are equally important.

In women younger than 35 with a good ovarian reserve, we generally offer 3–4 consecutive
IUI cycles. Performing them back-to-back helps maximise the cumulative chance of pregnancy.
Between 35 and 37 years, we usually recommend 2–3 IUI cycles before considering IVF. In
women 38 years and older, we may offer only 1–2 IUI cycles if the ovarian reserve is
satisfactory.

When ovarian reserve is reduced, IVF may be recommended sooner, irrespective of age,
because time becomes an important factor. We may also move directly or more quickly to IVF
in women with advanced endometriosis, where the pelvic environment may make IUI less likely
to succeed.

When do you tell a patient that further treatment is unlikely to help?

Most patients seeking fertility treatment have a reasonable chance of success with
treatments ranging from ovulation induction to IVF. However, there are situations where the
likelihood of success becomes extremely low and continuing treatment may cause more
physical, emotional and financial burden than benefit.

This may include women of advanced reproductive age, particularly over 40, with an extremely
low ovarian reserve, or patients who repeatedly produce poor-quality eggs, experience failed
fertilisation, generate consistently poor-quality embryos or have repeated embryo growth
arrest. Absence of viable sperm can also limit available options.

In these situations, I explain the prognosis clearly and discuss whether stopping treatment
or considering alternatives such as egg donation may offer a more realistic chance of
success. Some couples, even after understanding the very low probability, may still wish to
attempt one final cycle before considering alternatives.

We also do not proceed when pregnancy could pose a serious risk to a woman’s life, or where
treatment is not permitted under applicable ART regulations. Religious and personal choices
regarding treatment are always respected.

What do you do differently for a patient with low ovarian reserve?

In women with low ovarian reserve, our aim is often to maximise the number of eggs
collected rather than relying on a single stimulation cycle. Many such patients at
Jananam undergo more than one stimulation, and we frequently use dual stimulation when
clinically appropriate.

Dual stimulation involves performing one ovarian stimulation from the beginning of the
menstrual cycle, followed by a second stimulation a few days after the first egg retrieval.
This allows us to collect more eggs within a shorter period of time.

This is important because every retrieved egg will not necessarily be mature, every mature
egg will not fertilise, every fertilised egg will not become a blastocyst, and every
blastocyst will not be chromosomally normal. Embryo development also depends on sperm
quality and laboratory conditions.

For younger women, fewer eggs may be required to achieve a reasonable cumulative chance of
pregnancy, whereas women of increasing age generally need a larger number of eggs. So in
diminished ovarian reserve, our strategy is often egg accumulation and individualised
stimulation, rather than simply increasing medication doses.

Fresh or frozen transfer — how do you decide?

More than 90% of our embryo transfers are frozen embryo transfers. We
generally favour FET because it allows us to prepare the endometrium under more controlled
conditions.

During ovarian stimulation, gonadotropin injections can cause estrogen and sometimes
progesterone levels to rise well above physiological levels. In some patients, this may
affect endometrial receptivity. With a frozen embryo transfer, the embryos are
cryopreserved and transferred in a later cycle, allowing the endometrium to be prepared
using a natural or medically supported protocol.

A freeze-all approach is particularly important in women at risk of ovarian hyperstimulation
syndrome, such as some women with PCOS. Using a GnRH agonist trigger and freezing the
embryos can significantly reduce this risk.

Frozen transfer is also necessary when embryos undergo PGT-A, because the embryos are
biopsied and frozen while genetic testing is completed. Fresh transfer may still be
considered in appropriately selected patients where stimulation response, hormone levels and
endometrial development are favourable.

When is ICSI genuinely indicated, and when is it over-used?

ICSI is particularly useful in cases of severe male-factor infertility —
very low sperm counts, poor motility or a high proportion of abnormal sperm. It is also
indicated when sperm must be surgically retrieved from the testes, when there has been
previous complete fertilisation failure with conventional IVF, and when frozen eggs are
being fertilised.

ICSI involves selecting a single sperm and injecting it directly into a mature egg. This
differs from conventional IVF, where sperm are placed around the egg and fertilisation
occurs without direct injection.

We also use ICSI when embryos are being prepared for PGT, because removing surrounding cells
from the egg and controlling fertilisation reduces the possibility of contamination during
genetic testing.

At Jananam we tend to favour ICSI because it can reduce the risk of unexpected fertilisation
failure and improve the proportion of eggs that fertilise in appropriate patients. However,
the decision should still be individualised. ICSI should not simply be viewed as
automatically better IVF; the indication, egg quality, sperm parameters and previous
treatment history all matter.

What is your position on treatment add-ons?

We offer add-ons selectively rather than routinely. The principle is simple:
we recommend an add-on only when we believe there is a reasonable clinical justification for
that individual patient.

We commonly recommend PGT-A for women aged 38 years and above, and may also consider it for
repeated IVF failure or recurrent pregnancy loss. Couples with specific genetic conditions
may require PGT-M, while chromosomal rearrangements may require PGT-SR.

We do not currently perform ERA routinely. We have used ERA in more than 750
patients in the past, but in our experience it did not improve live birth rates sufficiently
for us to continue recommending it.

For selected women with repeated implantation failure or recurrent pregnancy loss, we may
recommend EMMA/ALICE testing to assess the endometrial microbiome and identify potentially
harmful bacteria.

Immune testing is reserved for a specific subgroup of patients with repeated implantation
failure or recurrent miscarriage. Where indicated, we may use endometrial immune profiling
and HLA testing to guide personalised treatment. We also perform assisted hatching for
day-three frozen embryos.

What is the most common mistake you see in patients who arrive after failed treatment elsewhere?

The most common mistake we see is that couples wait too long to resume treatment
after a failed cycle. Understandably, they feel disappointed, anxious and lose
confidence in treatment, but a long gap can sometimes reduce their future chances further.

After a failed IVF cycle, it is important to understand the likely reason for failure and to
have a clear backup plan. A detailed discussion with the treating doctor helps couples
understand what happened, what can be improved and what the next step should be. This clarity
often gives them confidence to continue treatment.

If embryos are remaining, they may still be transferred after suitable investigations and
lifestyle improvement. Couples should also remember that IVF success is not guaranteed in a
single cycle. What happens next depends mainly on the woman’s age, ovarian reserve and sperm
quality. Delaying treatment after failure may worsen prognosis.

What single factor most changes a couple’s prognosis that they can actually influence?

Lifestyle — and within lifestyle, maintaining a healthy body weight and BMI.
While age and ovarian reserve may not be modifiable, overall health can have a meaningful
impact on IVF prognosis and treatment outcome.

There is strong evidence that achieving an ideal weight can positively affect egg quality,
sperm quality, embryo quality and implantation, while also reducing the risk of miscarriage.
Smoking and alcohol should ideally be stopped, as both can adversely affect fertility in men
and women.

Adequate sleep is another important but often ignored factor. We encourage couples to
maintain around seven hours of sleep each night. Stress management also matters, and simple
practices such as meditation can help couples cope better during treatment.

In addition, folic acid supplementation is important, and existing medical conditions such as
thyroid disorders, diabetes, hypertension and vitamin D deficiency should be corrected. These
are practical steps that can genuinely improve factors affecting IVF outcome.

How many embryos do you transfer, and why?

Our policy is to transfer the smallest number of embryos needed to give a good chance
of pregnancy while avoiding the risks of multiple pregnancy. We do not transfer more
than two embryos under any circumstance.

In patients with PGT-A tested euploid embryos, we prefer single embryo transfer regardless of
age, because a chromosomally normal embryo already carries a good chance of implantation. In
women under 35 with a good-quality untested blastocyst, we also usually recommend elective
single embryo transfer. Between 35 and 37 years, we still advocate a single embryo transfer
if the blastocyst quality is good. In women aged 38 and above, we may discuss transfer of two
blastocysts depending on the individual situation.

When couples ask for two embryos, we explain the risks of twins after IVF, including higher
rates of miscarriage, severe vomiting, high blood pressure, diabetes in pregnancy, preterm
birth and caesarean section. For cleavage-stage embryos, the decision depends on embryo
quality. In donor egg cycles, we usually prefer a single blastocyst transfer.

What do you tell a 41-year-old considering IVF with her own eggs?

I discuss the prognosis honestly and compassionately. At 41 she is considered to be of
advanced maternal age, which usually means both reduced ovarian reserve and a higher
proportion of chromosomally abnormal eggs. These two factors together lower the chance of
pregnancy and increase the risk of miscarriage.

I explain that treatment is certainly possible, but she may need more than one cycle of
ovarian stimulation and egg collection to have a reasonable chance of success. Even with
treatment, success rates are lower than in younger women. We discuss that
after two to three egg retrievals, the live birth rate may be around 25%
overall, depending on egg reserve and embryo development.

We also discuss the possible role of PGT-A, which may help identify euploid embryos before
transfer. At the same time, I always explain the alternative of donor egg IVF, which offers a
significantly higher live birth rate, often around 70% per transfer. If she chooses to
proceed with her own eggs, we fully support her with individualised treatment and realistic
expectations.

Written and medically reviewed by Dr. Vani Sundarapandian, MD, DGO, FRCOG (UK),
Master’s in Reproductive Medicine (Australia) — founder and Medical Director,
Jananam Fertility Centre, Neelankarai, Chennai.