IVF & ICSI Treatment
IVF can fail with good-quality embryos because grading shows shape, not chromosomes. Implantation also depends on the uterus, including the endometrium, polyps, fibroids, chronic endometritis, or embryo abnormalities.
One of the most puzzling IVF situations is when you have good-quality embryos — well-graded blastocysts — but they still don’t implant. Everything looked right on paper. So why did it not work? One of the queries Dr. Rajesh Modi gets from his patients, who have gone through one or more embryo transfers that have failed, is why didn’t it work.
Implantation failure occurs when an embryo is transferred but fails to attach to the uterine wall and fails to produce a rise in beta hCG. This process is unlike miscarriage because a pregnancy is established through implantation before losing it. Recurrent implantation failure occurs when there are successive failures.
It helps to know what “good embryo” actually tells us. Grading assesses appearance — cell number, structure, the look of the outer layer — not chromosomes, and not whether the uterus is ready. Our guide to what a blastocyst is explains how grading works.
Implantation failure despite good embryos can stem from several sources.
The endometrium (uterine lining) may not be receptive at the time of transfer. The window of implantation is a narrow timeframe, typically 5–7 days after ovulation or progesterone start, when the uterus is most receptive. An ERA (Endometrial Receptivity Array) test can identify whether this window is in the standard timeframe or shifted — called a displaced implantation window — allowing the transfer to be timed precisely. The type of cycle used also matters: see natural vs medicated FET.
Structural uterine issues - polyps, submucosal fibroids, adhesions, or a uterine septum - can physically interfere with implantation, and are often silent on ultrasound. A hysteroscopy is often recommended for patients with recurrent implantation failure to check and treat the uterine cavity. Our patient guide covers what hysteroscopy before IVF involves.
Blood clotting issues (thrombophilia), immune factors, and chronic endometritis - inflammation of the uterine lining, often silent - can also impair implantation. Targeted tests and treatments exist for each of these.
Preimplantation genetic testing (PGT-A) of embryos can rule out chromosomal abnormality as a cause. This is the commonest single reason a good-looking blastocyst fails - aneuploidy is invisible under the microscope, and becomes more frequent with age.
One failed transfer is not a diagnosis — even a genetically normal embryo implants only about half to two-thirds of the time. After two failed transfers with good embryos, investigation is appropriate before transferring again, because repeating an identical cycle produces no new information.
The message Dr. Modi gives every patient: failed implantation with good embryos is a question, not a verdict. There are structured investigations to find the cause, and specific treatments to address each one. Most patients go on to achieve a successful pregnancy with the right workup.
Q: What is the ERA test and should I have it?
A: The ERA (Endometrial Receptivity Array) tests gene expression in the endometrium to find your personal window of implantation. It needs a mock cycle with biopsy before the treatment transfer, and is most useful after two or more failed transfers with good embryos — not as a routine test for everyone.
Q: Can chronic endometritis be treated?
A: Yes — with a course of antibiotics, then a follow-up biopsy to confirm it has cleared. Studies show improved implantation rates after treatment in women with recurrent implantation failure.
Q: If PGT-A tests show embryos are normal, what else could cause failure?
A: Investigation shifts to endometrial receptivity (ERA), uterine anatomy (hysteroscopy), immune factors and thrombophilia. Dr. Modi follows a structured protocol for recurrent implantation failure.
Q: Are there any symptoms of implantation failure?
A: No reliable ones. Cramping, spotting and breast tenderness happen in successful and failed cycles alike, and are often caused by progesterone support. Only the beta hCG test can tell you.
Q: How many failed transfers are normal before IVF works?
A: One or two is common and not a sign that IVF won’t work for you. Three or more with good embryos meets the definition of recurrent implantation failure and warrants a full workup.
The ERA (Endometrial Receptivity Array) tests the expression of certain genes in the endometrium to identify your personal 'window of implantation'. It's particularly useful after 2 or more failed transfers with good embryos. It requires a mock cycle with biopsy before the treatment transfer.
Yes. Chronic endometritis is treated with a course of antibiotics. After treatment, a follow-up biopsy confirms resolution. Studies show improved implantation rates after treating chronic endometritis in women with recurrent implantation failure.
If chromosomally normal embryos fail to implant, investigation should focus on endometrial receptivity (ERA), uterine anatomy (hysteroscopy), immune factors, and thrombophilia. Dr. Modi follows a structured protocol for recurrent implantation failure investigation.
