Dr. Ashish Soni — North India's first fertility super specialist and founder of Metro IVF Test Tube Baby Center in Ambikapur — has spent his career managing the cases that other clinics could not resolve. In this in-depth interview, he speaks plainly about the most important question in fertility medicine: why does IVF fail, and what can actually be done about it?

The conversation covers the clinical reasons that he most commonly finds when evaluating patients who have failed IVF elsewhere, the investigation he considers non-negotiable before any retry, and the message he would give to every couple who has been told that nothing more can be done.

"The explanation couples receive after a failed IVF cycle is almost never complete."

Dr. Soni, when couples come to you after a failed IVF cycle — sometimes after two, three, or more cycles — what is the most common thing they have in common?

They have received an incomplete explanation.

Almost universally. The couple sitting in front of me has been told that sometimes embryos do not implant, or that their egg quality was not ideal, or that the timing was not quite right. These explanations are not lies — they are technically true in some limited sense. But they are not specific. They do not tell the couple why the embryo did not implant. They do not explain what specifically was wrong with the egg quality or what caused it. They do not address what timing means or why it was suboptimal.

A complete explanation of a failed IVF cycle should be able to say, specifically: the cycle failed because of this identifiable factor, and here is the evidence from your cycle data and investigation results that supports that conclusion. If a clinic cannot give you a specific explanation — grounded in actual data from your cycle — then the investigation that would have produced that explanation has not been done.

This is the most important thing I want couples to understand. A vague explanation is not a diagnosis. It is a placeholder — a way of filling the space where a real explanation should be with something that sounds clinical but is actually an admission that the investigation was not thorough enough.

"The test that changes the most cases is the one that is most commonly not ordered."

What is the most commonly missed investigation in your experience?

Sperm DNA fragmentation testing. Without question.

I see it in case after case. A man with a semen analysis that was described as normal — or near normal — at two, three, sometimes four previous clinics. Good count, good motility, morphology within acceptable range. The previous clinics concluded that the male factor was not contributing significantly to the couple's infertility. The focus of investigation and treatment shifted entirely to the woman.

When I test sperm DNA fragmentation in these men — which I do routinely, for every male partner of a couple presenting with IVF failure, regardless of what the standard semen analysis shows — I find elevated DFI in a substantial proportion of them. Not unusual DFI. Severely elevated DFI in many cases — 30, 35, 40 percent. Levels that are clearly associated with impaired embryo development and implantation failure.

The semen analysis measures three things: count, motility, morphology. It says nothing about the genetic integrity of the DNA inside the sperm. A sperm with high DNA fragmentation looks identical under the microscope to a sperm with intact DNA. Moves identically. Has the same shape. The only difference is in what it carries — and that difference is invisible without the specific test.

When high DNA fragmentation is found and addressed — through antioxidant therapy, varicocele treatment where applicable, or testicular sperm retrieval — the next IVF cycle frequently produces embryos of better developmental quality. Not because the eggs have changed. Not because the protocol has changed dramatically. Because the sperm that is fertilizing the eggs no longer carries DNA damage that was compromising every embryo the previous cycles created.

This is the explanation that was missing. And finding it required one test that costs a fraction of what an IVF cycle costs and takes two to three days to return a result.

"The uterus has been examined, but has it been seen?"

What do you mean when you say the uterine assessment is frequently incomplete?

There is a difference between examining the uterus and seeing it.

Standard pelvic ultrasound examines the uterus. It measures the endometrial thickness. It assesses the uterine shape and size. It identifies large fibroids, obvious abnormalities of structure. What it does not do reliably is visualize the internal surface of the uterine cavity — the surface onto which an embryo must implant.

Small polyps — growths of endometrial tissue that can physically obstruct or disrupt implantation — are frequently missed on standard ultrasound. Intrauterine adhesions — bands of scar tissue that develop following uterine surgery, infection, or postpartum complications — are often invisible to ultrasound. A uterine septum — a congenital band of tissue dividing the cavity — may be detected on three-dimensional ultrasound but is definitively assessed only on direct examination.

The only way to truly see the uterine cavity is hysteroscopy — a procedure in which a thin camera is passed through the cervix into the cavity, allowing direct visualization of the endometrial surface in real time.

In the couples who come to me after two or three failed IVF cycles, hysteroscopy has been performed before a previous cycle in a minority of cases. In the majority, the uterine cavity was assessed by ultrasound and described as normal — which means only that the ultrasound did not detect an obvious abnormality. It does not mean the cavity was seen.

When I perform hysteroscopy on these women — as a routine component of my evaluation for anyone with a history of implantation failure — I find cavity abnormalities in a significant proportion. Polyps, adhesions, small submucosal fibroids, sometimes chronic endometritis that shows its characteristic granular endometrial surface. Each of these is correctable. Each, when corrected before the next transfer, removes a barrier to implantation that had been present throughout every previous cycle.

The question I ask every couple who comes to me after failed IVF is not "did you have a uterine assessment?" It is "have you had a hysteroscopy?" These are different questions. And the answer to the second is the clinically meaningful one.

"The implantation window is not the same for every woman. And nobody told her."

Can you explain the endometrial receptivity issue in simple terms?

Standard IVF practice assumes that the window during which the endometrium is receptive to an embryo — the implantation window — occurs at the same time in every woman. In frozen embryo transfer cycles, this means embryo transfers are performed at a standard time after progesterone begins: approximately five days for a blastocyst transfer.

This assumption is correct for most women. And for most women, transfers timed to this standard protocol result in implantation when embryo quality and uterine preparation are adequate.

But in approximately 20 to 30 percent of women with recurrent implantation failure, the window is displaced. Not dramatically — often by only twenty-four to forty-eight hours — but enough that a transfer performed at the standard time consistently misses the receptive phase. The embryo arrives before the endometrium is ready, or after it has already closed. Implantation fails. The same embryo, transferred at the right time, might have implanted successfully.

The test that identifies whether a woman's window is displaced is ERA — endometrial receptivity analysis. It requires a small endometrial biopsy taken at the time the transfer would normally occur, sent for genetic analysis, and returning a result that says either: your endometrium is receptive at this time — proceed with standard timing — or your endometrium is pre-receptive or post-receptive at this time — and here is the adjusted timing that will correspond to your personal window.

In women who have failed two or three transfers despite apparently good embryos and adequate lining, ERA should be discussed and considered. In my practice, when ERA is performed in this group, a meaningful proportion — not all, but a meaningful proportion — show a displaced window. When the subsequent transfer is timed to their personal window rather than the standard protocol, the outcome is often different.

This is not a difficult concept. It is not an experimental treatment. It is a logical response to the observation that the standard assumed timing might not be correct for every individual — and that individualized timing, confirmed by a specific test, is more likely to be correct than an assumption.

"When I see good embryos and no implantation, I think about the immune system."

How often do immunological factors contribute to IVF failure in your experience?

More often than they are tested for.

Antiphospholipid syndrome is the most clearly established immunological cause of recurrent implantation failure and early pregnancy loss. It is found through specific antibody testing — anticardiolipin antibodies, anti-beta-2 glycoprotein-1 antibodies, lupus anticoagulant. It is not found through standard pre-IVF blood work, because standard pre-IVF blood work does not include these tests at most clinics.

When a woman has had repeated transfers of apparently good embryos — including in cases where PGT-A has confirmed chromosomal normality — and has not had antiphospholipid antibody testing, the investigation is incomplete. The antibodies may be present. The abnormal clotting they promote may be disrupting the earliest stages of placental development every time implantation begins. And the treatment — low-dose aspirin and low-molecular-weight heparin initiated before the transfer — is straightforward and effective.

I also consider thyroid antibodies in every woman with repeated implantation failure — even in women whose TSH is within the general normal range. Anti-TPO antibodies affect the local immunological environment of the endometrium in ways that reduce receptivity. They are tested with a simple blood test. When they are elevated, optimizing thyroid function to the fertility-specific target level — TSH below 2.5 mIU/L — is a simple intervention that consistently improves the endometrial environment.

Natural killer cell abnormalities are more complex — the evidence base is suggestive but not as conclusive as for antiphospholipid syndrome, and the treatment options are less uniformly established. I assess NK cell activity through endometrial biopsy in women where other explanations have not been found, and I approach treatment with appropriate acknowledgment of the uncertainty in the evidence.

The consistent finding across all immunological evaluation is this: the tests are simple. The treatments are available. The only reason they are not being performed is that clinics with standard protocols have not included them. And couples continue to fail without knowing that a treatable cause has been present throughout.

"The protocol that failed twice is telling you something."

What message do you have for couples who are considering trying IVF again after multiple failures?

The protocol that has failed twice is not a protocol that deserves a third chance unchanged.

This is the message I would give to every couple considering a third or fourth or fifth IVF attempt at the same clinic with the same approach. The information embedded in two failed cycles is clinical information — about what the stimulation produced, about how the embryos developed, about whether implantation occurred, about where in the process the failure happened. That information, if it is read carefully and used to inform a fundamentally different approach, can change the outcome of the next cycle.

But a fundamentally different approach requires a fundamentally different investigation. Not a slight modification of the stimulation dose. Not the addition of a single new supplement. A systematic re-evaluation — of both partners — that identifies what has not been tested, tests it, and designs the next protocol around what the testing reveals.

This is what I do for every couple who comes to Metro IVF after repeated failure elsewhere. I read everything. I identify what is missing. I perform the missing investigation. And I design the next protocol from what the investigation actually shows.

Sometimes what I find changes the prognosis dramatically — a high DFI that was never tested, a displaced implantation window that was never identified, a uterine condition that was never seen. Sometimes what I find confirms that the previous approach was reasonably designed — and that the next cycle, with minor adjustments, is worth attempting. And sometimes what I find suggests that further autologous IVF is unlikely to succeed — and that the honest recommendation is a different path.

In all three cases, the couple is better served by the investigation than by another cycle without it. Because the investigation produces information. And the decision about what to do next — whether to try again, how to try again, or whether to take a different path entirely — should be made with the most complete information available, not with the information that was available after a less thorough work-up.

"Nothing more can be done is a conclusion, not an investigation."

What would you say to couples who have been told that nothing more can be done?

I would say: by whom, and on the basis of what investigation?

The conclusion that nothing more can be done for a specific couple's infertility can only be reached after a truly comprehensive evaluation — one that has assessed every relevant factor, tested every relevant parameter, and identified and addressed every correctable contributing cause. A conclusion reached before that evaluation is complete is not a conclusion. It is an assumption — an assumption that the investigation already performed is sufficient to reach a final clinical verdict.

In my experience, the majority of couples who arrive at Metro IVF having been told that nothing more can be done have not had a truly comprehensive evaluation. The sperm DNA fragmentation was not tested. The hysteroscopy was not done. The ERA was not discussed. The immunological panel was not ordered. The protocol was not redesigned around the specific findings of the previous failures because the specific investigation that would have produced those findings was not performed.

I am not suggesting that every such couple will succeed with further treatment. Some will not — the biology is what it is, and there are cases where the combination of factors is severe enough that the realistic prognosis, even after thorough investigation and optimal management, is poor. In those cases, I say so — honestly, with the specific evidence from the investigation that supports the conclusion, and with the alternative pathways that remain genuinely available.

But the conclusion must be reached after the investigation — not instead of it. Every couple who has been told that nothing more can be done deserves, at minimum, a consultation with a specialist thorough enough to confirm that conclusion with actual evidence — or to find what was missed and show that the conclusion was premature.

That consultation is what Metro IVF offers. And in more cases than the referring conclusion suggested, what we find changes the picture.

Booking a Consultation with Dr. Soni

If you have been through IVF that has failed — once, twice, or multiple times — and you have questions that have not been fully answered, Dr. Ashish Soni at Metro IVF in Ambikapur will give you the most thorough and honest clinical assessment available.

Bring every report from every previous cycle. He will read all of it. He will tell you what was missed. He will tell you what it means. And he will give you the most complete and honest picture of your situation that medicine can currently provide.

Metro IVF Test Tube Baby Center Ambikapur, Chhattisgarh metrofertility.in Led by Dr. Ashish Soni — North India's First Fertility Super Specialist

The specialist who finds what others missed. Book your consultation with Dr. Ashish Soni at Metro IVF today.