Expert View- Dr. Gautam Daftary,Founder & Chairman, Aksigen IVF
Q1. Despite advances in assisted reproductive technologies, recurrent IVF failure continues to be a challenge for many couples. What are the most common reasons behind repeated IVF failures, and how has the clinical approach to managing these cases changed in recent years?
Fertility treatment is unlike most other areas of medicine. It involves two independent reproductive systems that must function together, and the outcome depends on both. The medications used are largely biologics and carry their own sensitivity to storage, handling, and individual response. In addition, key stages of the treatment take place outside the body, under carefully controlled laboratory conditions, where embryologists play a direct role in determining outcomes. These factors add variability that is rarely seen in other specialities. That is the context in which recurrent IVF failure has to be understood.
Recurrent failure after two or three well-executed cycles is rarely due to a single factor. In current clinical practice, common possibilities include embryo aneuploidy which rises sharply with maternal age, inherited genetic abnormalities, poor ovarian reserve, poor endometrial receptivity, metabolic disorders, undiagnosed uterine or tubal pathology, semen abnormalities including elevated DNA fragmentation, and occasionally immunological or thrombophilic factors where the evidence continues to evolve.
The biggest change in recent years is the discipline that follows a failed cycle. Rather than simply repeating the same protocol with minor adjustments, the current approach at institutions that take this seriously is a structured re-evaluation of the couple before another cycle is undertaken. This includes reviewing the previous ovarian stimulation response, examining the embryology record with the couple, checking uterine cavity and tubal status, reassessing sperm quality with functional tests where indicated, and determining whether the embryo transfer strategy itself was optimal.
At Aksigen IVF, this discipline is embedded within our ROOTS Clinical Pathways framework. A repeat cycle without a formal review of the previous one is treated as a departure from protocol. Recurrent IVF failure deserves fresh clinical thinking rather than a repeat of the previous cycle.
Q2. There is growing emphasis on personalised fertility treatment rather than following a standard IVF protocol for every patient. What does personalised IVF involve, and how does it improve treatment outcomes?
Personalised fertility care is one of the most widely used phrases in this sector, and it means very different things at different centres. The real question is what that personalisation is actually built on.
At the operational level, personalised IVF involves a series of interconnected clinical decisions. The stimulation protocol is chosen based on ovarian reserve markers, age, previous response, and the risk of ovarian hyperstimulation. The choice between fresh and frozen embryo transfer is made on cycle-specific factors including progesterone levels rise and endometrial preparation, rather than a fixed clinic policy. The decision between conventional insemination and ICSI is made on semen parameters rather than applied as a default. The embryo selection strategy, including whether Preimplantation genetic testing (PGT) is appropriate, is discussed with the couple, in the context of the underlying evidence rather than positioned as a premium add-on. The timing and preparation of embryo transfer is matched with the patient’s window of implantation, with adequate progesterone exposure to ensure optimal endometrial receptivity.
Personalisation improves outcomes because it removes systematic errors of a one-size -fits -all approach. A young woman with high ovarian reserve may be at risk of overstimulation on a standard protocol. An older woman with diminished reserve may have an inadequate response on the same protocol. Semen issues are carefully evaluated to guide the most appropriate treatment strategy for each couple.
At Aksigen IVF, our personalised approach is built on three foundations. The first is clinical experience. Although Aksigen IVF is a relatively new institutional identity, it builds on the reproductive medicine practice previously known as Morpheus IVF, Mumbai, and draws on the pharmaceutical heritage of Bharat Serums and Vaccines, where documented protocols, laboratory discipline, and evidence generation have long been part of the organisational culture. The second is the international evidence base in reproductive medicine, which we continuously review and incorporate into our clinical pathways as the science evolves. The third is our own research programme- Recent peer-reviewed publications include a structured literature review of IVF protocols for women with Polyendocrine Metabolic Ovarian syndrome (PMOS), published in Insights in Reproductive Medicine (March 2026), and a scoping review on enhancing ART success in overweight and obese women, published in the Journal of IVF-Worldwide (2026). Further publications from our clinical and patient experience research programme are in preparation. Continued publication is, in many ways, our own form of external validation. If a clinical approach is sound, it should withstand peer review. Our ROOTS Clinical Pathways framework brings these three elements together-clinical experience, international evidence, and our own research, into a structured model of personalised care. Every clinical decision is guided by written pathways with defined criteria, ensuring that personalisation is evidence-based rather than improvised.
Q3. Artificial intelligence, genetic testing, advanced embryo imaging and time-lapse technologies are increasingly being integrated into fertility care. Which innovations are currently making the biggest impact, and how do you see these technologies shaping IVF over the next five years?
Each of these has a genuine place, and each is at a different point on the evidence curve. The more relevant question is not which technology is most exciting, but which is delivering measurable value in clinical practice today.
Time-lapse imaging is now standard in most advanced laboratories and is valuable primarily for undisturbed embryo culture and consistent morphokinetic assessment. The evidence that time-lapse itself improves live birth rates compared with conventional culture is modest.
Preimplantation genetic testing (PGT) has established value in specific indications, particularly known monogenic disease and structural chromosomal rearrangements. Evidence for universal PGT-A for aneuploidy screening remains mixed, and its use should be guided by patient age, clinical history, and indication rather than applied routinely.
Artificial intelligence is entering fertility care on two pathways. The nearer-term pathway is patient-facing guidance and clinical workflow support, where AI tools that answer common patient questions, structure treatment documentation, and monitor cycles are already useful. The longer-term pathway is AI-assisted embryo and sperm selection, where the technology is promising but robust peer-reviewed evidence supporting widespread clinical adoption is still evolving.
Over the next five years the most consequential change is likely to be tighter integration of these tools with each other and with the clinical record, so that laboratory data, imaging data, and clinical parameters inform decisions-making together rather than as isolated datasets.
Ultimately, the centres that will derive the greatest benefit will be those that integrate these AI tools & technologies within a disciplined clinical framework, rather than adopting them as standalone marketing features.
Q4. Male-factor infertility contributes significantly to infertility cases but often receives less attention. Are you observing any changing trends in male reproductive health, and what should clinicians and couples be more aware of?
Male factor contributes to approximately half of all infertility cases, consistent with the 2024 AUA-ASRM guideline update, and is the sole factor in around 30–40% of couples. Indian clinical practice reflects these international trends, supported by published data from the ICMR-NIRRH cohort in Mumbai and other Indian centres.
Two trends deserve particular attention. The first is the long-term global decline in sperm concentration and total sperm count, most recently documented in the Levine et al. 2023 meta-analysis covering 53 countries. Indian data broadly. Indian data broadly mirror this trajectory. The second is how we define what is normal. The WHO reference ranges for semen analysis have been revised downwards across successive editions of the WHO Laboratory Manual for the Examination and Processing of Human Semen. The lower reference limit for sperm concentration, for instance, has moved from 20 million per millilitre in earlier editions to 15 million per millilitre in the current edition. This has happened over the same period that population sperm counts have been falling. A man with a sperm concentration of 18 million per millilitre today is classified as normal under current WHO criteria but would have been classified as oligozoospermic under earlier standards. The clinical implication is that clinicians need to interpret semen analysis in its full context of overall fertility assessment rather than treat the reference range as an all-clear.
Beyond sperm count and motility, sperm DNA fragmentation is now recognised as an important component of male fertility assessment. Fragmentation indices are consistently higher in infertile men than in fertile controls, yet this parameter is not assessed through conventional semen analysis. It is particularly relevant in the evaluation of unexplained infertility and recurrent IVF failure. Despite this, male-factor infertility continues to receive less attention than it deserves. In many couples the male partner is evaluated only after a female partner has undergone extensive investigations. A first-visit semen analysis alongside the female evaluation, with proper counselling for both partners, would identify contributing male factor earlier and often changes the treatment plan.
Clinicians should be more attentive to modifiable contributors including obesity, tobacco, heat exposure, and specific occupational and environmental factors. Couples should understand that infertility is a shared clinical condition, not solely a woman’s health issue.
Q5. How significantly are factors such as stress, obesity, metabolic disorders, poor sleep, environmental exposures and delayed parenthood affecting fertility outcomes today? What preventive measures would you recommend for individuals planning a family?
Delayed parenthood is currently the single biggest driver we see in urban Indian fertility practice. It acts through female age, male age to a smaller extent, and cumulative exposure to other risk factors. It is not a matter of individual choice alone but reflects changing patterns in education, career trajectory, housing, and the economic cost of family formation. What is clinically important is that patients receive an honest picture of how ovarian reserve and egg quality change with age, well before they are trying to conceive.
Obesity and metabolic disorders including PCOS and insulin resistance affect both ovulatory function and IVF outcomes. Weight and metabolic optimisation before treatment improves the odds of a live birth in a way that no laboratory technology reliably matches. Male obesity affects sperm parameters and pregnancy outcomes as well.
Sleep, stress, and environmental exposures act in the background and are harder to isolate from other variables. They deserve attention because they are modifiable and because their cumulative impact over years is meaningful.
For individuals planning a family, the advice is straightforward. First, an honest reproductive check earlier rather than later, particularly if there is a family history of early menopause or if pregnancy is likely to be delayed beyond the early thirties. Second, weight and metabolic optimisation as part of routine preconception care. Third, seeking a fertility evaluation after six to twelve months of trying depending on age, rather than assuming that time alone will resolve the problem.
Q6. With more individuals choosing to delay parenthood, do you believe fertility preservation, including egg and sperm freezing, should become a more mainstream conversation in India? What role can preventive reproductive healthcare play in improving future fertility outcomes?
Fertility preservation should be a more open conversation in India, both in clinical practice and in public discourse.
The clearest indication is oncofertility. Sperm and egg preservation before chemotherapy or pelvic radiation is standard practice internationally and should be offered routinely to eligible patients before cancer treatment begins.
Elective egg freezing for women who anticipate delayed parenthood is a more nuanced discussion. Biologically the yield and quality of preserved oocytes is best in the mid-twenties to early thirties, which is not always the age at which women feel ready to make that decision. Counselling should be clear that egg freezing expands future reproductive options but does not guarantee a successful pregnancy.
Sperm preservation is technically simpler and less discussed. It is worth considering in specific clinical situations including certain occupational exposures, planned surgery involving the reproductive tract, and severely declining semen parameters.
More broadly, preventive reproductive healthcare means normalising periodic reproductive assessment, muck like preventive cardiovascular or metabolic screening. That includes awareness of ovarian reserve markers for women, semen analysis for men where indicated, and structured conversations about family planning well before infertility becomes a diagnosis. The Assisted Reproductive Technology Act, 2021 sets the regulatory framework within which fertility preservation is offered in India, and any expansion of access or awareness should continue to operate within that framework.
Q7. While reproductive medicine has advanced significantly, affordability and accessibility remain key concerns. What steps are needed to make high-quality fertility treatment more accessible across India while maintaining clinical standards?
Affordability and access remain among the biggest challenges in Indian fertility care, and they will not be solved through price competition alone.
Three structural interventions would materially improve the situation. First, expansion of insurance coverage for infertility diagnosis and treatment. India’s private and public insurance frameworks currently cover very little of this, which places the entire cost on the family. Even partial coverage of the diagnostic workup and a defined number of cycles would change the calculus for many couples.
Second, better upstream referral. Many couples spend two or three years in incomplete workups at general gynaecology or general medicine practices before reaching a fertility specialist. A shorter pathway from primary care to structured fertility evaluation reduces the total cost of reaching a diagnosis and often reduces the number of cycles required.
Third, improving the quality of care right at the outset. A cycle done well the first time is materially less expensive than three cycles done poorly. This is not only a laboratory quality question. It includes appropriate patient selection, honest counselling on the probability of success, and avoiding under-qualified centres where the true cost of failure is borne by the patient. The Assisted Reproductive Technology Act, 2021 provides a regulatory framework for this, and its consistent enforcement is an important step in improving access.
Geographic accessibility matters too. Well-organised partnerships between metropolitan fertility institutions and regional centres, with shared clinical pathways and shared quality standards, can extend high-quality care beyond major cities without compromising clinical standards.
Q8. Looking ahead, what scientific, technological or policy developments do you believe will have the greatest impact on fertility care over the next five to ten years?
Four developments are likely to shape the next decade.
First on the scientific front, one can expect deeper integration of AI-assisted assessment into laboratory workflow, particularly for embryo and sperm selection. Centres that adopt this well will use it to reduce variability rather than to replace clinical judgement. Refinements in endometrial receptivity assessment and further clarification of the appropriate use of PGT-A will change how transfer decisions are made in specific patient groups.
Second , on the technology front side, digital patient-support tools, structured treatment tracking, and AI-assisted patient guidance will move from being differentiators to being standard. The competitive gap will shift from having these tools to using them well.
Third, on the regulatory front, the maturation of national registry systems under the Assisted Reproductive Technology Act, 2021 will, over time, begin to make real-world outcome data available for the first time. That has the potential to reshape how patients choose clinics and how the sector benchmarks itself. It will also drive consolidation, because the compliance and reporting overhead is not sustainable for the smallest operators. Finally, the demographic trends will continue to shape fertility care, India’s total fertility rate has already moved below replacement in urban areas, and the policy conversation around reproductive health, fertility preservation, and preventive reproductive care will become more visible. At the same time, it is important to remain cautious about technologies that are still in the research pipeline, including artificial gametogenesis and mitochondrial approaches. These represent important areas of scientific research but are unlikely to become routine clinical practice within the next decade.
Q9. What message would you like to share with couples who may have experienced one or more unsuccessful IVF cycles and are feeling discouraged about their journey to parenthood?
An unsuccessful cycle is a difficult experience, and it deserves an honest response rather than false reassurance.
Two points are worth emphasising. The first is that a failed cycle is a clinical event that provides valuable information. The stimulation response, the fertilisation rate, the embryo development pattern, and the conditions at transfer help the clinical team better understand the situation and what may have influenced the outcome. That information should guide the planning of the next cycle. If the clinic proposes an immediate repeat of the same protocol without a structured review, it is entirely reasonable for patients to ask why.
The second is that discouragement after a failed cycle is a normal human response and it should be recognised as part of the clinical picture rather than something separate from it. Emotional care and counselling should be integrated into the fertility programme, not treated as an afterthought
At Aksigen IVF we believe that recurrent failure is a signal for the clinical team to re-examine its approach, not for the couple to lose confidence in reproductive medicine. A second opinion, a fresh diagnostic look, and a revised treatment plan are entirely reasonable requests, and the best clinics welcome that conversation, because they are central to delivering better care.
Q10. If you could recommend one priority that could significantly improve reproductive health outcomes in India — whether through awareness, clinical practice, technology adoption or healthcare policy — what would it be, and why?
If I could identify one priority, it would be earlier engagement with fertility awareness and evaluation, well before infertility becomes a diagnosis.
The most challenging clinical situations we see are influenced by factors that develop years earlier. Ovarian reserve at thirty-five is shaped by biology, health, and life choices made over the preceding decade. Sperm quality at thirty is similarly influenced by long-term lifestyle factors. Delayed parenthood is often driven by broader social and economic realities rather than personal choice.
Early engagement means three things in practice. First, structured reproductive health education for young adults so that they understand the biology of fertility, the changes that occur with age, and the options that exist. Second, normalising preventive reproductive check-ups as part of adult health, without the stigma that currently attaches to infertility as a diagnosis. Third, a shorter and clearer pathway from a first fertility concern to a proper clinical evaluation, so that couples are not lost in incomplete workups for two or three years before reaching a fertility specialist.
At Aksigen IVF this is more than a philosophy. Over the past year we have conducted one of the largest patient voice studies in fertility care globally, analysing more than 22,000 patient conversations from Indian and international online communities. The study, to be presented at ISPOR Asia Pacific 2026 in September and submitted for peer-reviewed publication, has given us important insights into what patients say is missing from their fertility care experience, and these have informed how we approach patient communication, counselling, and clinical engagement. Ultimately, better reproductive health outcomes begin with earlier awareness, earlier evaluation, and a better understanding of what patients need.
