Next steps after failed IVF transfers and miscarriages

    Hello,

    I am 33, my husband is 37 and we have had an unfulfilled pregnancy for 4 years.

    The 1st pregnancy occurred naturally in the 4th trimester, but ended in the 20th week of pregnancy after unilateral renal agenesis and unilateral renal dysplasia were diagnosed as med. ind. abortion. The induced labor was not sufficient to deliver the placenta, so that a scraping was necessary immediately after the birth.

    After that, I only became pregnant again naturally in the 12th trimester. This pregnancy ended as a natural miscarriage in the 7th week of pregnancy despite Utrogest Luteal support.

    We then underwent four IUIs in a natural cycle due to ideopathic infertility - all without success.

    We then changed clinics and carried out the following diagnostics on me as a woman: hormone monitoring (unremarkable, but progesterone at ES+7 borderline at 10); blood coagulation unremarkable; sugar metabolism unremarkable, but prophylactic 2x500mg metformin daily since then, karyogram unremarkable, TSH: 1.6, vitamin D: 40, AMH 2.7, AFC: 21. A uterine endoscopy was unremarkable, but the biopsy for plasma cells was conspicuous. The first antibiotic treatment with Doxy only reduced the count. The second course of antibiotics with metandozole was successful, no more plasma cells were detectable.

    Immediately after the last unremarkable control biopsy, a pregnancy occurred in the first natural cycle, but ended as a natural loss in the 6th week of pregnancy. Immediately after this, the natural cycle was successful again, but despite Utrogest Luteal support, another miscarriage occurred in the 6th week of pregnancy.

    After that, no more pregnancies occurred in three further natural cycles.

    My husband has had several spermiograms in the last three years. All above average in terms of volume and quantity. No fast-moving sperm, but so many slow-moving sperm that he was classified as having a normal spermiogram. A test for DNA fragmentation showed a value of 10 %. A karyogram on him was also unremarkable.

    We recently had our first IVF. Due to PCO (not PCOS) in the antagonist protocol. We were able to puncture 13 eggs, 10 of which were mature and all 10 fertilized (zymot chamber used). The first 3 embryos were transferred to prolonged culture, two stopped developing from day 2 to 3. One developed into a medium-quality blastocyst. A transfer with this blasto did not lead to pregnancy.

    The first cryo attempt in the next cycle took place in the naturally modified cycle. Ovulation was induced with Ovitrelle and then 3 Utrogest Luteal were taken daily, one Prolutex daily and 3 Progynova daily. Three PN were thawed, two of which developed into good quality blastocysts, one embryo stopped developing on day 3. One blasto was transferred, but again no pregnancy occurred.

    We have now frozen 4 more PNs, but we are undecided whether we should simply continue or whether we should carry out diagnostics to find out why, despite successfully treating endometritis at the time, no intact pregnancy occurred and after the two early losses no pregnancies occurred either naturally or after IVF.

    What could explain our course? What would be useful clarifications? How should we proceed?

    Many thanks in advance!

    Dear Franzi43

    First of all, I am very sorry that you have already come such a long way and have suffered so many miscarriages. I know that it is very difficult to deal with emotionally.

    Even though you have given a very detailed summary, I can't explain your case with certainty. The good thing is that you have already had many tests. At least the ones that are possible in Germany. But here are my comments: I understand that your clinic has to follow these protocols for legal reasons, but from a medical point of view and based on my years of working in Spain, it doesn't make sense not to fertilize all your eggs at the same time. With a PCO and probably a male factor, you need to check the quality of your embryos without freezing your eggs to see how many have reached the blastocyst stage and do a PGT-A (PGD) to check if they are chromosomally healthy. This would be our recommendation regarding the embryos. Then I would need to look at your entire medical record to decide which embryo(s) are eligible, but there are a few more tests to check your endometrium, your receptivity, your compatibility.... But first you need to determine whether your embryos are genetically capable of developing into a baby. If you still have eggs to fertilize, you should try and talk to your clinic about a conception test. But for a new cycle, I would try to fertilize all the eggs and get genetic answers.

    Don't hesitate to contact Vida if you want a more detailed opinion. I will be in Cologne next weekend in person and just an email away :)

    Yours sincerely,

    Dr. Kathi Spies.

    Ihr Vida Fertility Team <3

    Hello Dr. Spies,


    Thank you very much for your detailed answer.

    I was aware that PCO is a risk factor for miscarriages and poor embryo quality. But what do you think could be relevant from the male side, as you write that the male factor could probably also play a role?

    I am worried that the successfully treated chronic endometritis could have returned after two early abortions immediately after successful treatment and then no more pregnancies occurred either naturally or via IVF.

    Do you think the cause is more likely to be genetic or should I have the plasma cell test repeated?


    Thank you very much.

    Dear Franzi43,

    I hope you understand that it is hardly possible for me to form an opinion without knowing your entire medical history. However, it is important to understand that you need answers to two questions that are crucial for a successful pregnancy: a healthy embryo and a healthy uterine lining. Since the first aspect is age-related, I would first focus on creating all the embryos, seeing how many reach the blastocyst stage, and then doing genetic testing. Then and only then, if you get a healthy embryo, would I focus on possible endometrial testing.

    with L.G.

    Dr. Spies

    Ihr Vida Fertility Team <3

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