• video

Implantation problems and solutions worth considering: IVF Case Study #IVFWEBINARS

In IVF treatment implantation is the moment when the transferred embryo adheres to the wall of the uterus. Only after this adhesion, the embryo can receive oxygen and nutrients from the mother in order to grow and survive. Implantation failure may also happen after natural conception when the embryo does not nest in the uterus or when it nests but the woman has an early miscarriage.

Implantation failure is still one of the most important challenges for infertility doctors. Recurrent implantation failure (at least four failure with good quality embryos) is also an important cause of repeated IVF failure. Have you experienced implantation problems during your IVF treatment? What is the recommended treatment in such a case? What solutions IVF specialists offer to such patients? What solution will be best in your case?

Do you have more questions? We have the answers. Watch the recording of the webinar with Dr. Robert Najdecki, Scientific Director of Assisting Nature, Greece.

Implantation problems and solutions worth considering: IVF Case Study – Questions & Answers

Question:

If you have hydrosalpinx – how does this affect implantation?

Answer:

This is a very old, but very serious issue, and opinions vary. Active hydrosalpinx with elevated white blood cells and other blood results is a problem for implantation due to the inflammatory reaction in the whole region, both the uterus and the salpinx. We are able to proceed with the in vitro cycles and collect the eggs, but we must absolutely treat the hydrosalpinx before embryo transfer.

Question:

Are NK cells something that can develop over time, or a condition that one is born with?

Answer:

Generally, there are many options and a lot of discussion about what the real influence of NK cells  is – as I explained, they play an important role, but we are still far from understanding all these issues. In some cases, with recurrent implantation failure, the NK cell levels are elevated, but treatment using intralipid infusions is not always the solution. I know cases where trying to make something better, we elevated the levels of NK cells without any results and without any benefits for the patient.  We try to measure NK cells, but we don’t really know what to do with elevated levels, and then we advise our patients to try some therapies or to wait and see what will happen. This is under investigation now, and we have many opinions – some researchers say that it’s not very important, while others disagree – generally the immunological contribution to implantation failure is probably very small – it’s better to concentrate on some issues that are well known, for example to ensure the embryos are euploid, as it’s important to know that you are using normal embryos. We have to make sure that the uterus and it’s anatomy is perfect by doing a hysteroscopy, as some very small anomalies can play a big role in implantation failure, and these anomalies are very difficult to diagnose with 3D or 4D ultrasound or a hysterosalpingography. If we are talking about 80-90% of the reasons for implantation failure, we still have about 5-10% which are immunological/other and are still under investigation.

Question:

We’ve got 4 frozen embryos. Two of them were frozen on the 5th day after pick-up and two others on the 6th day (they became blastocysts a day later). We didn’t do PGD. Is it better to transfer one or two embryos? If two – should they be from the same day of vitrification? Should the embryos transferred be morphologically similar? If yes, why? I’m 36.

Answer:

Generally, we do either double or single embryo transfers. The single embryo transfer is absolutely correct in cases where we have done PGT and we know that we are using euploid embryos. In a case where we use unknown embryos, only blastocysts, and we don’t know of any previous history of implantation failure in the past, I’d advise you to start with a double blastocyst transfer. There is no difference between day 5 or day 6 – it’s a matter of the gynaecologist monitoring the endometrial stimulation and together with the lab, they will decide the day. In this case, we measured 5 days and in day 6, measuring from point 0, we perform the embryo transfer. If the result will be negative, then you have another two embryos to think about the possibility of doing a single or double embryo transfer. In the case of blastocysts, there are some morphological criteria they must fulfil before we vitrify them – if the blastocysts are vitrified, they are in good condition, and a check will be done after thawing them in the morning in the lab. In our lab, we are follow certain rules and we leave the embryos for a few hours (until afternoon) while monitoring their development, and if the blastocysts start to do automatic hatching or hatching is done, then this is a very good sign that these blastocysts are very active and alive. We have noticed that leaving the blastocysts until the afternoon allows us to collect more information about them. I think that every blastocyst that is alive and well after thawing has the possibility to be implanted in the uterus, but we of course choose these blastocysts in cooperation with the lab and the embryologists.

Question:

What is the difference between an endometrial scratch and a scissor scratch?

Answer:

There are many differences – actually, the endometrial scratch is used in some methods starting with some plastic pipettes, which are very easy to perform and performed in the luteal or follicular phase of the cycle, and this is around 70% of all scratches. However, hysteroscopic scratching is a completely different and more direct method – when the operator, using the hysteroscope and the optic control, is able to see the anatomical situation inside the uterus, they are able to perform deeper scratching using scissors. The scissors are around 2-3mm, and we perform one line of scratching from one tube opening to the other tube opening. Sometimes when the uterus is bigger or a uterine septum is present, we perform two lines of scratching – then it’s so impressive to see how the uterine cavity opens after this scratching. So, there’s a very big difference, and I’d like to say that we are not able to compare these methods – we have used only hysteroscopic scratching for the last 2-3 years, and we are thinking of changing the name from ‘scratching’ to ‘excision’ – we open the fundus of the uterus, it’s only a few millimetres, but it’s very important for implantation.

Question:

Is there an increased risk of implantation failure when 2 blastaocysts are transferred for patients over 40? I am going to be 46 at the stage of transfer. I would like to have 2 transferred to give a better chance of at least one live birth, but would like to know any increased risk of miscarriage due to my age.  

Answer:

When we are talking about our own eggs and our own blastocysts, there are many issues, and the most important issue is the quality of the blastocysts and their euploidy. If we know that the blastocyst is euploid, then there is no difference between the age of 30, 35 or 39 if the endometrium is growing properly, all the hormones are measured and the preparation of the endometrium is done correctly. Regarding egg donation cycles, we discuss this issue in one of our other podcasts – there are no differences in the implantation possibility based on the patient’s age, because the blastocysts are from young donors, and knowing their karyotype gives us the answers – in this case, it is the patient’s decision if she would like to have one or two blastocysts transferred. The difference in implantation potential is very small, so then, every decision is correct. If the patient is ready for twins, then we are able to do the double embryo transfer.

Question:

Is there a difference between PGS and PGT?

Answer:

PGT (prenatal genetic testing) is the new name for PGS and is divided into some other categories  by the ESHRE (European Society of Human Reproduction and Embryology). Talking about PGT, we are talking about former Prenatal Genetic Screening.

Question:

Can receptivity timelines change? I’ve had a successful live birth previously, 2 successful IVFs (ended in miscarriage) but have had 2 failed implantations with donor eggs. Should I have an ERA test done?

Answer:

After one or two failed embryo transfers, but with good, euploid embryos, we are thinking about the implantation window. The ERA test is very useful, but it is performed at least one month before by sampling the endometrium, after which we will have the results. If we, as doctors, analyse the failed embryo transfer, then we can easily come to the conclusion that in the second or third embryo transfer cycle, we must change the day of the embryo transfer to either one day before or one day after. This is the first step. The ERA test does the same; after some measurements and analysis, the ERA test tells you to do the transfer either one day before or after. An experienced reproductive specialist and experienced lab can solve this problem in the second or the third embryo transfer. However, we do of course have the option of doing the ERA test, and there are many papers and research about the influence of ERA for better pregnancy percentage, but of course it is possible for patients to do it while being monitored by doctors.

Question:

I had an ERA done over a year ago – should I have it repeated? Is there a chance that something changed?

Answer:

Every cycle is different, and the measurement of the time of the implantation window is valid for a few months. After a few months, the cycles and the hormone profiles change, so the implantation window is not the same. Using some medicines like estrogens or progesterone can also influence the window. The truth is, that at any time, this window is very personal and after 6 months, you must think about repeating these measurements and the simulation of how the cycle works again.

Question:

We have had 3 failed cycles, first two only fresh, no blasts. Third round we got one to blastocyst, we had it frozen and transferred the following month. We had a hysteroscopy and intralipids, but again failed. Is there anything else you could suggest?

Answer:

I have seen many hysteroscopies and many blastocyst transfers, but the point is the absolute synchronisation in the cycle. The first step is to achieve a euploid blastocyst, and for this, PGT is absolutely necessary to have the information about the karyotype and the blastocyst. Then, working with the endometrium and the uterus and performing a more aggressive hysteroscopic scratching, I believe, will be the solution. I have seen many hysteroscopies and have performed many hysteroscopies after previous hysteroscopies, and the results are very different. I mean that the frozen embryo transfer is absolutely the same as fresh transfer – we are supporting the freezing strategy, and the results are even better than in fresh cycles, because we are able to work with the endometrium independently, without time pressure – in the next cycle we are focused only on the endometrium and monitoring its correct growth. In my opinion, the most important is a euploid blastocyst, second is good preparation with hysteroscopy, and third is a properly prepared endometrium for the transfer.

Question:

What are the recommendations for using EmbryoGlue?

Answer:

There are differing opinions about EmbryoGlue having a positive influence as well as opinions about its negative influence. In our lab, we don’t use EmbryoGlue very often, because in our opinion, it’s not something valuable for the future development and for the implantation process.

Question:

I am 41, through 3 retrievals, only ended up with 2 blasts on the last round, after operative hysteroscopy to remove multiple polyps and hyperplasia. 1st transfer was negative, second frozen embryo transfer a biochemical. 7 days post transfer progesterone level was 11. Pleyrus once a day. Would this be too low a level of progesterone for proper implantation?

Answer:

There are many different opinions about what the level of progesterone should be in the luteal phase, and how to support it. Actually, if we believe in medicine and research, we must consider that the normal luteal phase support is enough for proper implantation. We must try another form of progesterone – we are now using subcutaneous injections of progesterone, waiting for stable levels of progesterone. But, in many cases, we cross the progesterone injections with vaginal gel and with oral drugs, to be sure that the level of progesterone is correct, and it’s easier to have stable levels. This is under investigation, but it is difficult to say that this is definitely the reason for failure. First if all, we don’t know the patient’s proper progesterone level – we haven’t got any previous research about it and it’s not possible to do it. We use some protocols for this, and a lot of them are very successful. I think that in the case of failure, the question is if the blastocyst was euploid, and if the karyotype of the blastocyst was correct. If we have recurring implantation failure after embyro transfer with euploid embryos, there is a clear answer: we must look into the uterus and into immunological mechanism, because the blastocyst is perfect. If we don’t know about the karyotype of the embryo, then there can be many reasons for the failure – first of all we must ensure the embryo is euploid, and then have really good, normal support with progesterone with the next cycle, and I’d like to advise you to use two or three different types of progesterone – endovaginally, orally or injected.

Question:

Can a laparoscopy and dye test detect the same issues as a hysteroscopy?

Answer:

These are two absolutely different techniques. During the laparoscopy we see the uterus, tubes and ovaries from the outside – it’s a very important method for diagnosis of, for example, endometriosis, which affects the structures outside of the uterus. A hysteroscopy, however, concentrates only on the uterine cavity. Therefore, there is no connection between these two examinations.

Question:

I’ve had 5 IVF cycles, a total of 9 embryos transferred. I had hysteroscopies before each cycle with implantation cuts. I also have a diagnosis of hyperplasia which has been treated with Clomid to keep the lining from being too thick. My transfers took place with the lining measuring around 13/14mm. I’ve never had a positive hCG test or home pregnancy test. What do you advise going forward?

Answer:

My first question is about the karyotype of the embyros – if the blastocysts are euploid or not. My advice would be to proceed with PGT and start again with planning a treatment plan and in this way, be sure that we are transferring normal and proper embryos. In around 60% of cases of unknown infertility, we are talking about embryo failure, so improper karyotype. If the embryos are checked and found to be proper, and after one or two transfers there is still no pregnancy, then we must look for some anomalies in the uterus or some asynchronisation of the endometrial maturation. 13/14mm is a very good lining thickness, but even 7mm lining thickness is enough to perform an embryo transfer. In this case, once we have information about the embryos, then maybe the next step would be to perform an ERA test, to find the exact implantation window.

Question:

I’ve had 6 embryos fail to implant so far – 4 single and 1 double transfer. I’m 38. I’ve had the endo scratch 4 times. Having my 7th embryo transferred next week, and that’s 1 of 5 left in the freezer. Do you think it is likely that we haven’t had a genetically normal embryo transferred yet? We have not had PGS due to cost, and have been advised against other tests and just to keep going. What would you suggest? They’re all day 5 blastocysts. No sperm issues. I’m on my third cycle.

Answer:

Without information on the karyotype of the blastocysts, we are able to make the same mistake again and again – we know of cases where 6,7,8 blastocysts are abnormal and this would explain the implantation failures. If we have the embryos frozen, the issue is more complicated because there is an option for a very quick PGT but it will be a 7 day embryo transfer – it is possible but it is under investigation to see if the results are the same as with a day 6 transfer. One solution is to agree with the statistics and to do this embryo transfer, and wait for good fate and to get pregnant, and if not, then to proceed with the PGT in all the blastocysts. This will give us the answers if there is any sense in continuing with the rest of the blastocysts, and without this information it is very difficult to decide what to do.

Question:

I had 4 failed cycles and I have never been pregnant. I tend to have polyps in my uterus and have had them removed twice. I’m 37. Now I’m on my way to have a 5th embryo transfer and the nurse found a ~2mm polyp in my uterus during a scan. My consultant says that a uterus polyp under 10mm would not have an impact on the implantation of the embryo. What is your opinion and your experience from your patients?

Answer:

The bigger polyps and the bigger abnormalities are very well known – but the smaller ones also may have an influence and cause negative results. A 2mm polyp is probably found by ultrasound, and because of this method, we cannot be sure that this is actually a polyp. One way to be absolutely sure is to perform a hysteroscopy. A hysteroscopy with polyp removal and scissor scratching may be the solution for you in this case.

Question:

When should the scratching be performed? In the same cycle as the ET or a cycle before?

Answer:

Actually, we perform hysteroscopic scratching in the cycle before the ET, but if we notice in the next cycle after the scratching that something has gone wrong and we see a liquid in the uterine cavity, then we would stop the monitoring of this cycle and we would focus on the following one. The second cycle after the hysteroscopy or the third – this is what we have found in our experience. We never perform an embryo transfer in the same cycle as the hysteroscopy – this is absolutely impossible. We perform the scratching in the follicular phase, 2-3 days after menstruation stops, and in every case, we use contraceptive pills to be sure of the level and the growing of the endometrium, and the next cycle or the cycle after will be the best for the implantation window.

Question:

I’m 44 years old and have had 8 own egg IVF cycles. One cycle resulted in a positive result when I was 39 years old but ended in miscarriage at 10 weeks. Since then, I have produced lots of eggs and a high number of good quality embryos in each IVF cycle, but had no implantation since the miscarriage. We are now considering donor eggs, but should I get any further tests before we do this? Sperm is good, I’ve had 2 hysteroscopies and a laparoscopy, and basic immune blood tests with no issues.

Answer:

If you decide to proceed with an egg donation programme, it’s probably a very good decision – first of all, because we will use a young donor’s eggs, but also in your case, I’d advise you to proceed with PGT so you have an absolutely clear view on the embryos before you transfer.  It’s a matter of price, but I think that it’s absolutely worth it for you to not pay for multiple embryo transfers but to pay once for PGT and only transfer the euploid embryos. Once you have euploid embryos, you can prepare your endometrium by a hysteroscopic scratching or proceed with the first transfer without the scratching, and in the case of failure, then do scratching and transfer the euploid embryo. I think in a few years, it will be in the guidelines to only transfer euploid embyros and to prepare the uterus with a hysteroscopic scratching.

Question:

I am going through early menopause. Does it affect the endometrium and implantation? I have frozen embryos with donor eggs.

Answer:

In your case, we must support your cycle with medicines, in order to have a normal cycle with bleeding and menstruation. This is very important to support your future embryo transfer. In my opinion, if we have this abnormality, and for example you menstruate every two or three months, then it’s better to use some substitution medicines or very light contraception to keep your cycle normal and to have the option to proceed with an embryo transfer every month.

Question:

I am going to be 43 in May, diagnosed with PCOS. AMH is 16, 2 failed IVF, 2 clear tubes with good endometrial lining. 1st IVF 10 retrieved eggs, 8 fertilised, all reached blastocyst stage but only one good one. 2 transferred but no pregnancy. 2nd IVF only 2 retrieved eggs as there was a cyst at the beginning of the cycle as the consultant did not down-regulate my cycle. No transfer because of poor egg quality. I have been taking metformin 1500mg for about 6 months, reduced to 1000mg last month as Victoza 1.2mg was added. What could be the cause of non-implantation with the first cycle? Should I use an egg donor next time or use my own eggs?

Answer:

If you have AMH 16, there is a possibility for you to use your own eggs, but only with the PGT procedure. It is well known that every woman who is around  40 years old, statistically, produces around 10 eggs per year. I say 10 eggs because you will have 1-2 menstrual abnormalities without egg production, so if we are talking about 10 eggs per year, then it is possible for 7-8 of those to be abnormal. Looking for those 1-2 normal eggs is difficult, and then we must realise that every year after 30 it’s getting more and more difficult. Without PGT procedures, we have no idea what we are transferring- I advise you to try with your eggs, but only with PGT. If good, euploid blastocysts are found, then it is possible to win this war. If there are no euploid blastocysts, then egg donation would be an option for you, instead of waiting and losing time doing other procedures. PGT with your own eggs, and then if not, then an egg donation programme.

Question:

Following a recent failed donor egg cycle, my bloods showed elevated white cells (13). Is there something further that I should investigate in regards to this?

Answer:

This is a very simple issue and it’s easy to investigate this – these are signs of inflammatory disease. It may be connected with our procedures or not. Sometimes, it could be tooth inflammation, or something completely unrelated, so it’s something for an internal medicine doctor to investigate, and to be sure that in the next attempt, the white blood cell count should be under 9000. There are also other inflammatory index measurements which you can monitor with your doctor to solve this issue.

Question:

What is the risk of scissor scratching for a person who is on warfarin and who also has adenomyosis?

Answer:

Before the hysteroscopy, we measure all the blood factors and then there are ways to do it, for example to change this medicine for Heparin for around the time of the hysteroscopy. There are no elevated risks for performing a hysteroscopy on a patient with Heparin support, and we have done it many times without any problems. If the operator is experienced and the hysteroscopy is short, then there shouldn’t be any issues with bleeding or anything else. However, we must discuss this with the anaesthesiologist and other specialists to solve this issue, and always in cooperation with your gynaecologist, however this procedure is very possible. This procedure is more diagnostic than therapeutic, and the incisions in the fundus of the uterus are very small, 2-3mm incisions where we go through the tissue until we see the blood vessels – the point isn’t to damage the blood vessels but to stop in the layer above the vessels. The risks are very small and the experience of the operator is very important in this case.

#IVFWebinars are brought to you with the help of our Partners:
Eizellspende.de
Donor Conception Network UK

About the Author

Robert Najdecki

Robert Najdecki

Robert Najdecki MD, PhD is a Reproductive Gynaecology Specialist. His experience in diagnosis and treatment of fertility disorders, such as endoscopic surgery is long and extensive and includes more than 6000 stimulated cycles. Dr. Najdecki’s vast experience in reproductive gynaecology and embryology has contributed greatly to his achievements in the field, e.g. the second baby birth through IVF technique in Poland and the first transvaginal, ultrasound OPU (oocyte retrieval), which resulted in second IVF baby being born in the nation. These successes opened new doors to a new era in IVF techniques that continues till now. Assisting Nature IVF clinic provides international couples who are struggling to conceive with the most advanced donor eggs programs in Greece.

Leave a Reply

Your email address will not be published. Required fields are marked *