Recurrent implantation failure and ART adjuncts — structured oral station (12 minutes)

Opening prompt — "How do you approach this patient?"

Model response — say it in this order: ^[1]

• "I would first define her situation using the ESHRE 2023 good practice recommendation: RIF is when transfer of embryos considered viable has failed to result in a positive pregnancy test sufficiently often that the cumulative predicted chance of implantation exceeds 60 per cent. I would calculate her cumulative predicted chance before labelling her RIF."
• "Before any adjunct, I would complete the evidence-based workup: pelvic ultrasound and hysteroscopy for cavity pathology, exclude and treat a hydrosalpinx, and address modifiable factors — smoking and weight, because obesity lowers live birth even from euploid embryos."
• "Then I would counsel her on each adjunct she has asked about, using the ESHRE add-ons traffic light and the best trial evidence, with full disclosure that roughly 95 per cent of add-on recommendations rest on low-quality or consensus evidence."^[1][2]

Examiner is listening for: the ESHRE definition, the cumulative-chance threshold, the structural and modifiable workup first, and the evidence-quality caveat. ^[1]

Probe 1 — "She wants PGT-A. What do you tell her?"

• "The STAR trial (Munné 2019) randomised 661 good-prognosis women to PGT-A versus morphology. The ongoing pregnancy per embryo transfer was 50 per cent PGT-A versus 46 per cent morphology — equivalent — and per intention to treat 41.8 per cent versus 43.5 per cent — also equivalent. PGT-A did not improve overall outcomes."^[3]
• "There was a per-transfer signal in women aged 35 to 40, but not per intention to treat, and no demonstrated cumulative live-birth benefit. The ASRM 2024 committee opinion states that the value of PGT-A as a routine screening test has not been demonstrated."^[4]
• "I would also counsel that mosaicism can cause false positives that lead to discarding potentially viable embryos. So PGT-A may improve the per-transfer rate but is not a fertility treatment and does not improve the cumulative chance of a live baby."^[3][4]

Probe 2 — "She wants an endometrial scratch."

• "The Cochrane 2026 review of 24 RCTs and 7234 women found the effect of endometrial injury on live birth unclear — odds ratio 1.12, 95 per cent confidence interval 0.98 to 1.28 — consistent with no effect or a small improvement. Clinical pregnancy was similarly unclear and the procedure probably causes mild to moderate pain. I would not recommend it routinely."^[5]

Probe 3 — "Her last euploid transfer failed. Why?"

• "Even a euploid blastocyst has a positive predictive value for implantation of only 50 to 60 per cent — Cimadomo's 'black box of implantation'. So a failed euploid transfer does not mean the diagnosis was wrong."
• "Obesity, reduced embryo quality, developmental delay and a history of previous RIF all independently depress live birth from euploid embryos. I would address the modifiable factors, particularly her weight, before reaching for more adjuncts."^[6]

Probe 4 — "She is in tears about the money she has spent."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Acknowledge the grief first: "I can hear how hard this has been, and I am sorry you have been through so much. You have not done anything wrong."
• Then commit to an honest, evidence-based plan: "My job today is to make sure that anything we do next is supported by evidence, and that you understand exactly what each option can and cannot do. We will build a plan together, and I will not let you pay for something the evidence does not support."^[1]

Probe 5 — "What is your overall plan?"

• Define by cumulative chance; complete the structural workup; address weight and smoking; then offer adjuncts only by ESHRE evidence tier with shared decision-making.
• If autologous options are exhausted, counsel toward donor oocytes or surrogacy as a structured decision, not a failure.^[1]