Failed IVF/ICSI - what to know next time
15 Replies
LoLam - November 27

Hi,

We've just had a failed IVF/ICSI protocol, and I am wondering if there is anything I should know to ask my doctor about.

First of all, I am 30 years old. I have had extensive endometriosis removed this August, and had a lap the August before as well. My husband has lower motility, but excellent DNA fragmentation. We've been trying for over 3 years now.
I also have chronic pelvic pain, and a small bladder. I had a lot of cramping after our transfer (for at least an hour), and cramping throughout the entire 2ww. I also tend to feel like I have some kind of infection, which they are also wondering if I have Interstitial Cystitis...but leary that it's just the endometriosis.

They retrieved 21 eggs, 18 were mature, 15 were fertilized. All embryos received a grade 3 (out of five, with 1 being strongest, and 5 being weakest). Only 3 made it to blastocyst, 2 were transferred. One is frozen.

What should I do now? An FET?

What should I ask my doctor about? What if he doesn't change my protocol?
Should we ask for Genetic Testing?
If I'm feeling depressed from everything, could that affect future cycles?


Any info would be appreciated!
Thanks,
Lola

 

Dr Smith - November 28

You chances of a term pregnancy with a single frozen-thawed blastocyst transfer is about 10-15%.

Endometriosis, left untreated, can seriously impact embryo implantation. You had lap treatment in August and that would have kept the endometriosis at bay for 3-6 months. We have tried putiing the patient on Lupron for 2-3 months prior to stimulation. Because you do not cycle on Lupron, the endometriosis quiets down. This is a "medical" approach rather than a "surgical" approach. The Lupron is not permanent either and the endometriosis returns in 3-6 months. Endometriosis, especially endometriomas (endometriosis on/in the ovary) can serious affect egg quality. This results in lower grade embryos (i.e. Grade 3 out of 5) and a lower than usual blastocyst rate (i.e. 20% instead of the 50% expected based on your age).

Another thing to check out is immunologial testing. Endometriosis is, in part, an autoimmune disorder. As a result, your Natural Killer Cell number and activity may be elevated. This means that your immune system rejects the developing embryo. For more information, see: http://www.millenova.com/tests/nkassay.asp Warning! Not all docs believe that the immune system is involved and pooh-pooh the idea of immunological testing. Personally, I think its important, but that's only my opinion. You may run into some resistance if you suggest imunological testing.

The protocol was fine and I see no reason to change it. I don't think genetic testing is an issue because you are relatively young and your husband's SCSA was good.

 

LoLam - November 28



Dr. Smith,

Thankyou very much for equipping me with your information. I did have endometriosis removed from one of my ovaries, and that ovary produced few eggs (the other one hyper -produced). I don't believe that my clinic does any immunological testing, but I don't know if they would do it if I asked. I did have an EFT however, and everything turned out normal on that ...I have no idea if that is a part of any immunity testing.

In case I need to 'take the bull by the horns' here, should I be requesting that I do a lupron protocol, or book another surgery in before we go ahead with IVF/ICSI again?

Also, with only one frozen embryo, should we do another fresh cycle in the hopes for more frozen blasotcysts, before going ahead with an FET?

Once again, Thankyou so much for the information you are able to provide!

Lola

 

Dr Smith - November 28

The question about Lupon vs. Lap, I can't really advise you. Its a medical question and I'm not qualified (not an MD). Lupron has side effects. It puts you into a medical menopause (hot flashes, etc). Lap is no fun either. Both are temporary fixes. I'd discuss the options with your doctor.

If you have the resources ($$$) to go through another IVF cycle, I'd say that's the way to go. As I pointed out, the chance of pregnancy from a single frozen-thawed blastocyst is pretty low. If there's more to freeze from the next cycle, this will improve your chances of sucess from FET (now or in the future).

 

LoLam - November 29


Thankyou once again for your info! I have one more question for you, if you are able to answer it.

Just one more question...

I don't know if you know anything about bacterial issues, but I've had recurring infection for the last 3 years, since I've been off the pill and TTC. I've seen Urologist specialists and had cystoscopies, I've had 2 laparoscopies for treatment of endometriosis. I have been treated for trichomonis (was never tested for it, and not even sure what it is), and mycoplasma (not sure exactly what that is either), but treated anyway. Always pain though in bladder/reproductive organs.

Do you know of any clinics in Canada/Ontario that have extensive knowledge of bacteria testing? In addition to immunity testing? Could bacteria be affecting implantation at all? And potentially my husband's motility?

Thanks so much.
Lola

 

Dr Smith - November 29

Although originally from Vancouver, B.C., I moved to the US 23 years ago (and yes, I miss Vancouver). I'm not very familiar with the programs north of the 49th. Because your question is more of a clinical nature, I will forward your question to Dr. Jane Miller, the RE I work with. I think she may give you some information about the impact of recurring infections on reproduction. She may be able to provide you with enough information to ask you doctor the right questions.

 

LoLam - November 29

That is wonderful, thankyou so much! How will I hear from Dr. Jane Miller?

I just got news from another clinic that they have a Dr. who is doing research on genes and clotting in individuals with endometriosis. I'm not sure what this means. Is this something worth pursuing if my current clinic is not interested in further investigation at all?

Thanks,
Lola

 

Dr Smith - November 29

Dr. Miller will read your post and reply on the board (soon). She's pretty busy, but she will answer.

I don't think genetic studies about blood clotting in endometriosis patients will help. They don't relate to your problem.

 

Dr Jane - November 30

I'm sorry about the failed cycle! Your cramping after transfer and for the subsequent 2 weeks is significant history. It is highly suggestive of an autoimmune problem resulting in implantation failure. This is not uncommon with your history of endometriosis and pelvic pain - and - if it exists it can be treated. I would strongly suggest you have bloodwork for Natural Killer cells - both number and activation - sent to Millenova Laboratories in Chicago. This is a specialty laboratory that performs immune testing for people with implantation failure and recurrent pregnancy loss. We work closely with them and have helped many patients with histories like yours. I would not do another cycle until these tests (and others for antiphospolipid antibodies) are done. Interstitial cystitis can be diagnosed with a cystoscopy and treated appropriately. It would not produce the symptoms you had post ET.

 

LoLam - November 30


Dr. Jane,
I really appreciate your information!
I have chronic infection as well, pain all through my reproductive system. Along with other symptoms that no one seems to think is important enough to look at.

If my clinic does not agree that there is significant data to support immunological testing, what should I do?
Could bacterial issues be a problem? I have heard about the work of a Dr. Toth in NYC, do you work with this?

Is it possible to have an underlying infection , or bacteria that is robbing us of our fertility?

Thanks,
Lola

 

Dr Jane - November 30

Lola,
Dr. Toth had been talking about infection and infertility for many years. If you were concerned I'd have your doctor do an endometrial biopsy (ouch) and have the tissue tested for endometritis. Appropriate antibiotic treatment could be begun if there was an infection. However, that is not likely and you history is so highy suggestive on an autoimmune problem that could be diagnosed with the appropriate blood studies.I'm sorry for the chronic pelvic pain and it is likely due to the endometriosis and its sequella but people with your gyn history so often have an autoimmune problem that it would be helpful to investigate this area before embarking upon another cycle.

 

LoLam - November 30


Dr. Jane,

Thankyou very much for the info! I'm sorry to keep bothering you...

Is endometriosis a probable cause of chronic infection as well? I treat for a yeast infection at least 10+ times a year. I assume it is yeast, but I have throbbing tubes too... Or do you mean that a compromised immune system could likely be the real culprit behind this.

I had an EFT done through Yale, is the Endometrial biopsy you are speaking of, different from the one I had?

This is very helpful for talking to my Dr.!

Where is your clinic located?

Lola

 

Dr Jane - December 1

Hi Lola,

Yes, I think we are on to something: a compromised immune system could be the cause of all this. I am familiar with the endometrial work done by Dr. Klineman at Yale. The research is great but, as of yet, there are no consistant clinical applications. What I was suggesting is something much less sophisticated: an endometrial bx. sent to a reference pathology lab to look for infection - ie - endometritis. But I don't think that is the cause of the problems. Immunoogic studies are key given your pelvic/gynecologic history. I'm sorry for the pain that you live with! I know that this is a quality of life issue as well as a great effort to conceive. We are located in Englewood Cliffs, NJ which is 2 miles from NY City (just over the Geo. Washington bridge.)

 

LoLam - December 1


Dr. Jane, Dr. Smith,

I just wanted to thankyou so much with the information you have been able to provide. I wanted to let you know that this information has helped me to know what questions to ask, and to go out and ask these questions of other clinics right away to try and find the care that I need. Only one has said that they agree with immunity/infection testing. After having researched endometritis, I agree with everything listed, and now have more knowledge!

Thankyou very much once again, this has really meant a lot in helping me try to improve the quality of my life as well as try to have a baby.

Thanks!
Lola

 

BekyVice - December 4

I'm interested in learning all about the infections and immuniology portion of infertility... and it reminded me (with 2 failed IUIs and 1 failed ICSI) that I might have implantation problems due to some previous infections.

In my adult life I've had 9 sexual partners, and was on the Pill throughout my twenties/thirties. With each partner, I'd get bladder infections so bad that I'd have to be rushed to the emergency room, as they quickly developed (within 4 hours of having sex) to UTIs, in which I would urinate dark red blood until they could get antiobiotics inside of me. This happened with each partner.

Does this mean I have a predisposition to not "accepting" foreign matter (sperm) into my reproductive system and should have this checked out? Would this be any cause for concern during my upcoming IFV/ICSI cycle that I should mention to my dr.?

I never thought to mention this, as it's been a long time since I've had an infection (have been with DH for 5 years and never had infection with him.) Did I build a tolerance?

Any light you can shed would be so helpful.

 

Dr Jane - December 5

Which brings us to the age-old question: Do you test everyone for everything?? Well, immunologic and infectious testing cannot hurt - except the immunologic testing can be quite expensive. As far as the barrage of UTIs: It is interesting that there are times in a woman's reproductive life when she might have recurrent yeast infections or UTIs. They may be only partiallly treated any one time and, with activity (ie - sex) they flare again. Remember the proximity of the urethra, vagina, and rectum. In some women they are actually closer than in others. Cross contamination may occur - even in the most "careful" woman.

In your post you mentionned that in your "20s and 30s" you were on the Pill. Does that mean that you are in your 40s - or late 30s? A careful review of stimulation sheets and embryo records from previous cycles might reveal more obvious reasons for cycle failure - ie "older eggs" - than the clandestine ones. As we get older it often boils down to being a"numbers game". On which cycle will you get the right egg-sperm combiination?
I hope it is your next one!
Yours,
Dr. Miller

 

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