What are the recommended next steps after IVF with donor eggs fails?
Even though egg donation may be presented by some clinics as the “magic bullet” that helps patients even with the most severe degrees of infertility. The reality, unfortunately, is somewhat different – we all understand that there are no guarantees in medicine. Even though egg donation is one of the most effective fertility treatments, it still does not guarantee a 100% success rate. Failures do happen.
What to do, then, when an egg donation cycle fails? Is there another way, or should you just keep trying? We asked these questions to three experts.
Our experts are:
- Dr. Uljana Dorofeyeva, Intersono Clinic, Ukraine
- Dr. Maria Arqué, Fertty International, Spain
- Dr. Raul Olivares, Barcelona IVF, Spain
Answer from Dr. Dorofeyeva
I would like to help the patients to understand—and this is well-known—that the statistical results for an initial successful IVF treatment, even using donor eggs, is around 55-60%. This is the data from our clinic. What we usually recommend to our patients, and what we focus, is the cumulative pregnancy rate per completed cycles using all the donor eggs that the patients have received. Our recommendation is to use at least 8 vitrified or fresh donor oocytes in order to produce a certain number of blastocysts. We usually transfer 1 blastocyst in the first cycle and we have a few more left for subsequent cycles in case the first one fails. The cumulative pregnancy rate using all the blastocysts from one cycle in our clinic is 87%.
This means that after each and every cycle that turns out to be unsuccessful, we make a deep analysis of the reasons why that particular cycle failed. This could be because of endometrium receptivity, implantation failure, or the immunology of the patient. By considering all these mutual factors and understanding what to should be done next and changed in order to prepare the patient for the next cycle, our success rate in subsequent cycles is higher. So, the patient needs to be educated about the reasons for failure and needs to focus on the cumulative pregnancy rate, as well as continuous treatment, and also rely on the doctor until a successful result is achieved.
Answer from Dr. Arqué
In the case when the IVF with donor eggs fail, it is a time to stop and to analyze the situation. The first thing we have to look at is the quality of the embryos that we’ve transferred. It is important to see if embryos were transferred at the stage of day 3, if they were blastocysts, in that sense, what was the grading of those embryos, and look also at the donor herself. See if she has done any other cycles, how they went, if she has had children and it’s a fertility proven donor. It might be the case that the failure is due to the poor quality of the donor, this is not the thing that is going to happen the most often, but it has to be looked at. In the case that we think, or we consider that this is the cause, what we have to do is to change for a different donor.
The other thing we have to look at is the male side, the male factor, we have to discard if there are no problems that we have not seen before, so there might be a place to arrange a genetic test like DNA fragmentation or a FISH test, and depending on the results, we might consider them and discuss with the patient. The indication for doing PGT-A. And we mustn’t forget also that we have to look at fact that there are no uterine factors that might explain the failure like polyps, fibroids, or any kinds of malformations in the uterus. We have to look at the window of implantation, and in that case that we think that this might be the problem, there might be an indication for doing an endometrial receptivity test. And also depending on the case, there might be a place to indicate an immunological test also to see if there might be a problem there. Once we have looked at all those things, it would be a matter of having another conversation with the doctor and analyzing all those factors and addressing all the issues that we have seen to aim to have a positive outcome with the following cycle.
Answer from Dr. Olivares
The first thing we have to know is that, unfortunately, even in the best scenario, we do not have 100% success rate, so most of the time when we have a single egg donation that has not worked, our recommendation is going to be to move forward and try again. However, there are cases in which we may really think there is something wrong, and in this scenario, we have 2 branches. The first one is to study if there is anything wrong on the male side and this is important regardless of the quality of spermiogram. Sometimes a patient with a normal sperm may have a high percentage of sperm carrying genetic issues, and this is going to have a big impact on the genetic quality of embryos and may explain a lot of recurrent, negatives, or miscarriages. There is a test called FISH that basically assesses if this percentage of sperm issues are normal or not.
The other branch is going to be if there is anything wrong in the endometrium, the uterus, or in the body of the patient. We can assess if there are clotting problems, checking our study of the thrombophilia. We can see if there is any kind of autoimmune disorder especially antiphospholipid syndrome. These are tests that are going to be done by blood tests. There is a local process in the endometrium that can interfere with the implantation by checking for chronic endometritis, doing endometrium cultures, recommending hysteroscopies to get a direct view of the cavity and confirm that everything is OK. Shaft, endometrium qualities. And there are other studies that are still really recent and controversial that basically let us know if the window of implantation, and that means we are transferring the embryos when the endometrium is fully receptive. This is a test called ERA and it’s still controversial if it’s really useful. Because this window of implantation depends on when the patient starts the progesterone, so in some cases, it could be useful to start the progesterone before or later. To make sure that whenever we transfer the embryo, this endometrium is fully receptive.
But in any case, implantation issues are probably the most complicated to study because the majority of the information and most of the tests we have are tests that give us information about an embryo, or when there is no embryo. Assuming what happens when there is an embryo, or when there is not, can sometimes be slightly tricky. So, basically, the first step should be to consider if it’s worth repeating without doing any other tests. And then we think if there could be something else wrong, then check the male side, regardless of the quality of the sperm, and carry out some tests on the uterus, the endometrium, and in the body of the recipient to see if there can be anything that can be interfering during the implantation of those really good embryos.