Recurrent IVF Failure

Written by: Dr. Mohammed Agdi

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Recurrent IVF failure is defined when a patient undergoes multiple cycles of embryo transfer without resulting pregnancy. This is one of the most frustrating and stressful conditions for both patient and physician.

 

Several reasons may explain failed implantation. It could be due to the embryo or endometrium or both. Other co-factors may be involved. However, in many cases we cannot explain the reason for recurrent IVF failure.

 

The most known causes of IVF failure are:

 

• Advanced maternal age

• Slow embryo development in the IVF Lab

• Thick shell on the embryo and difficulty in hatching

• Intrauterine abnormalities like; polyp, fibroid, scaring or inflammation.

• Fluid collection inside Fallopian tubes

• Fluid collection inside uterine cavity

• Difficult embryo transfer technique 

• Immunological factors

• Chromosomal abnormalities in the embryos

• Maternal medical illnesses

• Suboptimal ovarian stimulation during IVF cycle

• Poor sperm quality

 

Management of recurrent IVF failure is a challenging process and has financial impact of couples. Several investigations are required in this kind of women to identify possible treatable causes or factors.

 

Common investigations include:

 

• Thyroid Function

• Thrombophilia screen

• Immunological testing

• Hysteroscopy

• Chromosomal testing

• Diabetes Screen

• Endometrial Receptivity Array (ERA)

 

This test (ERA) is designed to identify, accurately, the implantation window when the lining of the uterus is most likely to accept the embryo for implantation and produce pregnancy. It is one of the new invented advanced diagnostic tools in assisted reproductive technology. It examines 236 genes involved in the endometrial receptivity. This window of implantation may differ from one woman to another. Thus, 30% of women who suffer unexplained recurrent IVF failure have displaced implantation window. Therefore, if it is the case, this test tells the doctor the right timing of embryo transfer.

 

Recently, scientific researchers showed significant improvement in pregnancy rate in women in whom their test proved displaced implantation window and timed embryo transfer is performed in the correct proposed time.

 

The process, simply, involves the followings:

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1. The test requires the woman to undergo IVF cycle, as usual, and then all formed embryos will be frozen, so no fresh embryo transfer will take place. 

2. In a future cycle, a frozen embryo replacement cycle protocol will be used.

3. The woman will take estrogen tablets starting from the beginning of her period and the lining of the uterus (endometrium) is monitored for growth to reach certain thickness.

4. The woman will start taking progesterone additional to estrogen and the procedure will be scheduled.

5. On a specific day, instead of real embryo transfer is performed, only a sample from the endometrium will be aspirated and examined.

6. The results will be available in, about, 10 days and the results will be discussed with the patient.

7. A recommended protocol will be designed for the correct timing of transferring the frozen embryos in a future cycle.

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Usually, the management is directed towards the cause if recognized. However, commencing treatment improves the outcome but it doesn’t always means the pregnancy will occur. In many circumstances, no cause is identified (unexplained recurrent IVF failure) but your physician may try empiric therapy hoping it may improve the outcome.

 

The following treatment modalities are widely used for recurrent IVF failure based on your assessment by your physician:

 

• Endometrial scratching

• Endometrial receptivity array (ERA)

• Prednisolone

• Intralipid therapy

• Freezing all Day 5 embryos in fresh cycle and replacing them in non-stimulated cycle

• Proper management of male factor by an andrologist to improve sperm quality before attempting IVF cycle

 

Not all women with recurrent IVF failure are the same. Therefore, planning future IVF cycle with your physician depends on careful review of your condition and the records of your previous cycles.