When Your Best Embryo Fails: Is There Still Hope?

In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols explores one of the most common emotional pitfalls in IVF: the heartbreak of a failed transfer using your top-graded embryo. Using a relatable medical school analogy, he explains why even “average” embryos can still lead to pregnancy—and why the term “best” isn’t a guarantee of success.

 Learn how embryo grading works, what research says about implantation rates with AA vs. BB embryos, and how uterine factors, thaw survival, and plain old chance can affect outcomes. If you’ve ever felt hopeless after a failed transfer, this episode will help you reframe your expectations and rediscover your hope.

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Transcript

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Today we talk about what happens when your best embryo doesn't work and why that doesn't mean you're out of hope. I'm, Dr. Mark Amols, and this is Taco about Fertility Tuesday. Today we're diving deep into YFL transfer. Even with your top membryo doesn't mean you're out of options. But let's be real. You're told this is your best embryo. You transfer it, you wait, you test, and it's negative. And now your brain goes to that spot and ask, if the best didn't work, why would the others work? This is totally valid. It feels like the floor dropped out. But what patients often don't realize is this best doesn't mean guaranteed. It doesn't even mean that much better when we're talking about embryos that, already passed the transfer criteria. So what do I mean by that? I'm saying some Membross are at least good enough, and it doesn't have to be the best to have success. One analogy I came up with is the idea of becoming a doctor. Getting into medical school is hard, but everyone who makes it is going to be very sharp. Now, some people are going to pass their exams with higher grades. Some people are going to pass their boards in the first try. But at the end of the day, some do become neurosurgeons and others become family doctors. Now, the doctors with the better scores, yeah, they may get into the more competitive programs such as neurosurgeons, and there's going to be some doctors who end up becoming family doctors, and let's say some programs that aren't as competitive and yet they're still very good doctors. Matter of fact, they could have even had some of the highest grades medical school. The point is, the family doctor still saves lives. The family doctor still diagnoses, treats, and heels. Well, embryos are the same. Not every embryo is a neurosurgeon, but if it's been selected for transfer, it's still a doctor. That means that embryo pass their boards, it can do the job. Just like medical school doesn't let people graduate who don't meet the criteria, we don't transfer embryos that are not viable. So basically, if we're putting it in your uterus, it's because it has a chance. The point is, there is a minimum threshold that they must meet to be able to consider for transfer. And once they do, they're in the game. So, again, whether your embryo looks like a neurosurgeon with perfect ICM A beautiful tropctoderm and expanded exactly on day five. Or you might have an embryo that's a solid family Dr. Average morphology, slower development. Guess what? They all have the potential to succeed. So let's talk about what do we mean by best embryo. We're not talking about your embryo is going to become the smartest kid or the healthiest kid. We can't even guarantee that it's going to be the one that has success. What it means is that statistically, when we look at certain features, there is a higher probability that that embryo will do better than the others. But this is just statistics. No one actually knows the embryos is can do better. There are so many other things that can be involved. But let's first focus on morphology. That's where we look under the microscope. We look at the embryo and we then assessor certain things. One of them is called the intercellular mass. This is the part that becomes the baby'usually abbreviate icm. the next thing we look at is the trophectoderm. This part is what becomes the placenta. And then the third thing we look at is the expansion and how far along it is in the blastocyst stage. This usually comes as a grade with a number which represents the stage, the first letter which represents the ICM and the last letter that represents the trophectoderm. So an embryo grade AA means it looks pristine. Both the inner cell mass and the tropactoderm look very good. BB would be considered average and CC would be considered the lowest quality. Now, if you listen to one of my prior podcasts about grading, you would know that some clinics do it different. Some use a scoring system that uses three letters or three numbers. Some use one that has six letters or six numbers. In the situation where there are three letters, such as ab, C, C will be the worst. B would be completely average. Now, in the system where there's an B, cde, F C is just above average and the letters below it are going to be the worst. So what does the research say about this? The research does show that there is some benefit to highly graded morphology. Meaning A's are better than B's than, great than C'WE. Also know that more of the upoid embryos will come from the A's versus B versus C'in. One study, they had a 76% ongoing pregnancy rate when they put back embryos with ICM grade A. But that dropped down to 13% when putting back a grade C embryo. Now, to note that was with the three grading system called the gardener system. Now, when you add euloid status, this starts to shrink. The difference isn't as great, and that's because now you remove the embryos that were abnormal. But what's interesting was that big of a drop. The question is, what about the ones that are A versus B? Well, the difference was smaller. Think like 60 versus 50. That's a shift. But it's not the difference between hope and no chance. It appears through a lot of these studies that ICM is a major component in determining whether an embryo will work or not. Now, it's important for every clinic to figure out what works best for them. We look at our data all the time, and we look at what works best at our clinic. So the point you should take from this is not that the ICM is more important, but just the fact that morphology does play a small part, and that reduces whenever you do testing. And it also is a smaller drop when you compare A's and M, B's versus A's and C's. The point here is, is that if your best embryo was an AA and didn't work, and now you have a PB or even a BC embryo left, it's still a chance. And if your clinic only transfer embryos that are, average or better, like we do, then every embryo you transfer is still med's, school quality. They're all trained. They all can do the job. But let's go a little deeper, because even perfect embryos fail, and sometimes average embryos succeed. The question is why? Well, that's because the embryo is just one part of the equation. One part we don't think about is the uterus. Yes, we check the uterus. We make sure it looks good. But what if there is inflammation in there that we're not realizing? Or what if maybe there'palms that were undiagnosed? Or what if the timing is off and the person needs an ERA test? All those things will make even a perfect embryo not work. One thing we don't think about, too, is the thawing process. Sure, an embryo may survive the thaw, but who knows that the embryo didn't suffer some issues, such as maybe it's on its way out and you don't know it. Now, you put this embro back, which you think is normal, looks beautiful, but in reality, that embryo was already dying, and you didn't know that. And now you feel that you didn't get pregnant because you thought your best embryo didn't work, when in reality, your best embryo didn't have a chance because even though it survived the thaw, it didn't survive the thaw as well as you thought. And then there's just bad luck. Sometimes we know the human body is in the math equation. Even with perfect conditions, sometimes it just doesn't work. Studies estimate that even for euloid high quality blastocyst, the chance of implantation is around 60 to 65%, not 100%. So even your best embryo failing doesn't mean something's wrong. It just means you played the odds and came, up short this time. So let's circle back to the big question. If the best embryo didn't work, is there still hope? Absolutely. And that's because best means graded on a curve. It'not graded on the destiny of that embryo. It'because all embryos transferred are considered viable. Because even average embryos result in babies every single day. We see this. And if you got more embryos, it means you've got more chances. One of the most important things I tell my patients are a failed transfer is in a failed cycle. It's just a step in the process. Don't get me wrong, it's absolutely scary. Even just one transfer failing can make you lose hope. And having an embryo that, you're told is the best embryo of the best failing feels like the floor just dropped out from under you. But now you know that that grading just means it had potential. It doesn't mean it's going to guarantee success. And when it doesnt t work, it doesnt t mean we shouldn't worry that there could be problems. But you should look at it more that it doesnt mean that there'also something wrong. Whether it'your AA embryo or your average embryo, if you still have an embryo left, you still have a chance. I don'want. You to lose hope. The difference between the best embryos and the average embryos is not as great as the best embryos and the worst embryos. What I can tell you is most clinics do not freeze bad embryos. If they do, it doesn't make it wrong. But, it's important for you then to know what are the chances then with those embryos if they only use a three grade system, if your clinic doesn't transfer those embryos, then you know your embryos are either average or better and that the difference is going to be small. So the next time you feel defeated after a fail transfer, remember, not every embryo is a neurosurgeon, but sometimes the family dog comes in and saves the day. Just Remember, all embryos finished embryo school and are all destined for potential success. Thanks for joining me again on this week's Talk about for Tille Tuesday. If this episode helped shift your mindset, let me share it with someone who needs it. As always, I greatly appreciate everyone who listen to this podcast. If you love us, give us a five star review on your favorite medium. But most of all, keep coming back. I look forward to talking to you again next week on Taco about Fertility Tuesday.