Recurrent implantation failure and ART adjuncts — structured SAQ (15 marks)

(a) Definition (3 marks)

One mark for the ESHRE description, one for the 60% threshold, one for why fixed counts are discouraged. ^[1]

• ESHRE 2023 description: RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions; ESHRE frames RIF as a secondary phenomenon of ART.^[1]
• Threshold: when the cumulative predicted chance of implantation for the number of embryos transferred exceeds 60 per cent and implantation has not occurred, further investigation is warranted.^[1]
• Why fixed counts are discouraged: older definitions (Coughlan 2014: four good-quality embryos in three cycles under 40; Polanski 2014: two cycles with four cleavage or two blastocysts) ignore the patient's age and embryo quality; the cumulative-chance model individualises the threshold and avoids over-diagnosing RIF and over-investigating.^[1]

(b) Evidence-based workup and modifiable factors (4 marks)

One mark each for structural workup, hydrosalpinx, modifiable factors, and the evidence-quality caveat. ^[2]

• Structural workup: pelvic ultrasound and saline sonography or hysteroscopy to exclude submucous fibroids, endometrial polyps, intrauterine adhesions and congenital anomalies.^[2]
• Hydrosalpinx: exclude by ultrasound and hysterosalpingogram, confirm by laparoscopy; salpingectomy or proximal occlusion if confirmed (an evidence-based intervention).^[2]
• Modifiable factors: smoking cessation; weight optimisation — her BMI of 32 is relevant because Cimadomo 2023 found obesity associated with lower live birth (OR 0.66) and higher miscarriage (OR 1.8) even among euploid transfers.^[2]
• Evidence-quality caveat: disclose that roughly 95 per cent of ESHRE add-on recommendations rest on low-quality or consensus evidence before offering any adjunct.^[2]

(c) PGT-A counselling (4 marks)

One mark for STAR per-transfer, one for STAR ITT/conclusion, one for the subgroup nuance, one for ASRM 2024. ^[3]

• STAR (Munné 2019): 661 good-prognosis women; ongoing pregnancy per embryo transfer was 50 per cent PGT-A versus 46 per cent morphology — equivalent; per intention to treat 41.8 per cent versus 43.5 per cent — equivalent.^[3]
• Conclusion: PGT-A did not improve overall pregnancy outcomes in all women.^[3]
• Subgroup nuance: a post hoc per-transfer benefit was seen in women aged 35 to 40 (51 per cent versus 37 per cent) but not per intention to treat; there is no demonstrated cumulative live-birth benefit.^[3]
• ASRM/SART 2024 committee opinion: the value of PGT-A as a routine screening test for all patients undergoing IVF has not been demonstrated; recent multicentre RCTs found overall outcomes similar between PGT-A and conventional IVF.^[4]

(d) Endometrial scratch and intralipid (4 marks)

Two marks for the scratch evidence with the CI, two for the intralipid conflict-of-evidence. ^[5]

• Endometrial scratch: the Cochrane 2026 review (24 RCTs, 7234 women; primary analysis 8 low-risk studies, 4402 participants) found the effect on live birth unclear — OR 1.12 (95% CI 0.98 to 1.28), consistent with no effect or a small improvement — and the procedure probably causes mild to moderate pain. Do not offer routinely.^[5]
• Intralipid: the Singh 2019 single-centre RCT (102 women) reported higher clinical pregnancy (34.62 per cent versus 14 per cent) and live birth, but the Busnelli 2021 systematic review found no impact of intravenous intralipid on IVF outcome, and the evidence quality is low. A single small positive RCT does not overturn a systematic review; ESHRE does not recommend intralipid routinely.^[6][7]