Endometrial receptivity – programming the IVF success

According to the international morphological trading – 3BB embryo is a good one. But as I had told you, at the beginning of presentation there is a very slight correlation between this external appearance and genetic competence, and for sure 3BB embryo can have 40% of being genetically normal. There is a correlation with age, in most cases, the patient who is 43 years old will have lower chances than women who is 39. However, it’s not that simple because we should take into the account, AMH level, the number of antral follicles by ultrasound. The general somatic status because a reproductive area is not a separate system in our organism. If a woman has some diseases or she has to take medication which can affect the quality of eggs. Unfortunately, at times, we do not obtain a good embryo even in very young patients, f. e. in patients has a kidney condition, they need to take very harmful medications, that will influence the quality of the embryos. Also, some immunological diseases like endometriosis – it can affect the quality. If, we are talking about the embryo arrest, which means that the embryo stops growing properly. It usually is associated not only with egg quality but also with sperm quality. We need to examine both partners. I would need more information form you on how many follicles were obtained if you had surgeries on ovaries and a little bit more about medical history. When it comes to the difference between the natural cycle and the frozen cycle. There were plenty of trials comparing the results in outcomes of a natural cycle and frozen cycles. Most of these were done on a large number of participants. It demonstrated that there is no difference in the outcome, however, you should take into the consideration that in natural cycles, we do not prescribe any hormonal medication, during the protocol for hormonal replacement therapy we have to prescribe some kind of hormones and this causes huge stress in the organism. Sometimes a patient has contraindications that do not allow us to prescribe this medication. In this mode of the natural cycle, it will be the first-line therapy. I prefer to make everything more natural, and even when we have a very strong standardized protocol for each situation, I always tell my patients that less is more and, in medicine, we should avoid additional interventions. When we can make a natural cycle and frozen embryo transfer, we can do it. If we are talking about egg retrieval in natural stimulation or ovarian stimulation, we have a lot of arguments that egg retrieval in ovarian stimulation cycle is much better.

These type of cases inquire pre-implantation genetic testing. As I’ve mentioned 3BB embryo is considered a good quality embryo, but we have no information about its genetic competence. In this situation, when the embryo is abnormal, there is no implantation but about 20% of pregnancies, the pregnancy will be stopped. Your organism will fight and will make natural defence and will not allow pregnancy to progress, and woman will miscarry. We observe this pattern when pregnancy is initiated but unfortunately is interrupted approximately from week five till week eight. In 90% it is associated with genetic problems. I think there is a great chance that the reason for your miscarriage was a genetic problem of the embryo. The truth is that in most cases, we expect to see the problems, but not all types of diagnosis can detect them. If there was just a so-called histological examination, there is a chance that it was not possible to detect it. We have to perform the immunohistochemistry (IHC) analysis. We should find the prevalence of CD138 and CD56 to assess the activity of the inflammation. Unfortunately, other types of diagnosis cannot detect these CD clusters. I would recommend performing another embryo transfer but only after pre-implantation genetic testing. You should check the report from the endometrium diagnosis and check if you had performed immunohistochemistry testing.

CD56 it is a special type of immune cells which we will not detect, or we will detect them in a very small amount. If we have no inflammation the pathologist will assess your material, staining will need to be done, to detect these types of cells and only after assessing these, we can conclude if there are pathology and inflammation in the endometrium.

I see three points that are suspicious to me. We always try to find the reason for miscarriage, in about 80% of cases of miscarriage are associated with genetic abnormalities. If, we are talking about early miscarriages, so week 5-8 the risk is even higher. The miscarriages at 11 weeks, on the other hand, are associated with some problems with the blood, f. e. antiphospholipid syndrome. The diagnosis and the tactics in these situations are very different – that’s why we always investigate it after miscarriage. If you have the information about the genetic status of this abortion material, we can interpret it for you. You have mentioned that you had done the test for antiphospholipid and it was negative, which will also give more chances there will be no problems now with your next pregnancy. I’m a bit confused about why you have very high doses of hormonal treatment. So you take 2 mcg of estrofem orally and also estrogel, so these are all estrogens, and you need to understand we have to increase the doses of estrogens when we do not observe a proper growth of the endometrium. Inappropriate growth of endometrium means that it is already compromised, so we should fix that reason. My recommendation is to do the hysteroscopy and try to assess endometrium before embryo transfer. About ERA test, it doesn’t matter what kind of test system we are talking about. There are BeReady and ERA test. If we are talking about hormonal replacement, we’ll start with estrogens, and when we achieve a good thickness of the endometrium – we’ll start with progesterone. So when we could do the embryo transfer, on day six – we do the biopsy and send the material for investigation. The idea is to repeat that the preparation material which we plan to do during embryo transfer. Otherwise, there is no sense, because if we change the conditions, we won’t have a different result.

Endometriosis is a great problem in the reproductive field. The impact of endometriosis depends on its stage. Endometriosis is associated with the development, and there are four stages: the first and the second stages are called superficial. If all women who suffer from endometriosis didn’t conceive naturally, there wouldn’t be a problem with overpopulation in the world. Endometriosis has a huge impact on the quality of eggs, on the quality of fallopian tubes causing mechanical problems and so-called tubal factor of infertility. It also provides information on the endometrial cyst in ovaries causing bad prognosis not only on the quality but also on the number of eggs. There are many aspects, and I would need more details to provide you with a thorough answer. You need to take into account that the endometriosis can involve different tissues. There is a so-called extragenital endometriosis, which affects lungs or non-reproductive organs. According to the conventional gynaecological assessment, we perform a physical examination, and there can be some focus of endometriosis on the cervix in the uterus. In this case, we can detect it visually. When we are talking about ultrasound diagnosis, there is very different objectivity if we are talking about endometriosis in the uterus or the ovary or pelvic area. If we are talking about endometriosis in the uterus, we have some specific signs, the shape of the uterus is wrong, its size is enlarged. Endometriosis is a progressive inflammation disease. Unfortunately, we have no confirmed data on the reason for the formation of endometriosis. We have around seven theories on this. The most modern one is called the epigenetic theory of aetiology of endometriosis. We might know that there is a kind of premorbid form which causes the formation, but we have no idea what condition will be the trigger for progression of the endometriosis.  The golden standard to check the endometriosis is a surgical diagnosis. It is laparoscopy and when we insert the camera in the abdomen and we can detect it and remove it at the same time.  Unfortunately, during the regular gynaecological examination, we can assume there’s endometriosis. We can only confirm it by laparoscopy and hysteroscopy.

Those are very different procedures that have different aims. Scratching is just a very small injury, it’s not the diagnosis. It’s a when we make a small injury on the endometrium to try to initiate a local immune response in this area. In the early 80s, there was some data that scratching can enhance the quality of endometrium, thus it can increase our results. Hysteroscopy is the golden standard of diagnosis and treatment when we insert the camera into the uterus, on the monitor we see all the internal conditions of the uterine cavity, we can even record this video and then show the patient. During this procedure, we detect the pathology and fix it. When it comes to scratching, we just insert the catheter, insert the catheter and make a very small injury in the uterus.

There are different indications for this. We prescribe antibiotics only in cases in which we detected inflammation. First, we need to identify the microorganism to be able to provide the antibiotic treatment, not empirically just prescribe medication which can have a wide range of effect. We should provide very targeted therapy. Laparoscopy is just another level of the diagnosis, so those are non-comparable things. Sometimes, after laparoscopy, when we detect signs of inflammation, and we have lab confirmation that there is inflammation, it means there will be another clinical diagnosis. We prescribe antibiotics if there is a need. You should understand that any kind of inflammation is an issue, especially chronic inflammation.

Both of those tests are very similar. The technique is just the same. We perform a similar preparation of endometrium. Both testing systems inquire the biopsy of the endometrium, so we do the biopsy, the various testing systems have their own cultures where we should place this biopsy sample, and then we send it to the clinics. The main offices in BeReady tests are located in Tartu in Estonia. We also have an office in St. Petersburg. ERA test is also quite affordable now, and the labs are located in different countries. Usually, it’s just one lab in one country. In my perspective, both tests are very effective, so I don’t have any preferences. BeReady test is cheaper, but I don’t see any difference between them, from my experience. Our idea is to make our treatment more affordable for patients, that’s why we have been using BeReady test for the past 1,5 years. We still do ERA tests for patients who f.e. live in Spain, it is easier for them to do it in Spain as the main office is located there.

Well, no. Sensitization is associated with severe risk in the last stages of the pregnancy when we see the conflict between the mother and the fetus. Nowadays, it’s not a big problem when we talk about appropriate observation during pregnancy. We have a solution for this without any doubt. When we have Rh-negative mother and Rh-positive fetus in the first pregnancy – we always have to make the injection of antirhesus immunoglobulin at the 20 – 25 weeks. Then just the second injection will be done 72 hours after delivery, it’s just prophylactically. Unfortunately, if we don’t do this, we can face severe complications during the second pregnancy. I want you to realize, that during the first pregnancy, we cannot see a severe complication because the pathogenesis of this process inquires getting to know this antigen and antibody.

It’s a Granulocyte colony-stimulating factor (G-CSF) – a growth factor which is produced in natural life by granulocytes that’s why we call it in that way. It’s involved in many processes in our life, but it has a crucial role in the reproductive field. It controls many things f.e. maturation of the eggs, growth of the follicles, which is necessary to initiate the process of ovulation, and G-CSF controls and regulates these processes. When we have the deficiency of this growth factor, we have some problems. That’s why there are many trials where we add G-CSF in different doses during ovarian stimulation. We aim to increase the competence of the eggs. When we add G-CSF 36 hours before egg retrieval to increase the rate of mature eggs as sometimes during standardized triggering in controlled ovarian stimulation, some patients, because of their features – do not produce mature eggs. Supplement with G-CSF can fix this problem, but the best results G-CSF has demonstrated with fixing the problem in recurrent implantation failure. There are different types of administrating in the mode of intrauterine infusion. But it was the first mode of application which wasn’t that effective compared to the subcutaneous way of administration. In cases of recurrent implantation failures, we administer G-CDF for two or three days, from the day of an embryo transfer, but it provokes a transient reaction in your blood. Sometimes, there is just one injection or injections every day. It depends on the medical history, a number of previous negative attempts, but also BMI. It leads to producing leukocytes which should be controlled by your physician, it’s a normal reaction. It gives very good results.

There was such a theory. The uterus is characterised by the great flow of blood. The uterus can invert five hundred times it has a great blood and vessel net. About 10 years ago physicians were all excited by the idea that insufficient blood supply to the uterus could provoke problems and cause miscarriages. After that, there were a lot of trials. Even now, some small universities try to assess these levels of blood. However, there is no conclusive evidence that this is true. There are no reference levels for ‘normal’ blood supply. It depends on so many features, and we have information that uterus has a lot of resources and we cannot assess it, unfortunately. There are some techniques like doppler regimen or doppler made by ultrasound, but we can see dynamic levels which do not provide us with good information. According to current data, it is not that important, it does not have a crucial impact, and certainly, it does not lead to miscarriage. So, do not think about that. I’m sure the reason is not associated with the problems with blood supply.

It depends on what types of immunological issues we are talking about. We have understood that there is a strong connection associated with three points in our body: thyroid, ovaries and endometrium. If we have some problems with the thyroid, we have increased chances of immune defects in the endometrium, and that’s why we should assess these problems. Immunological issues or defects cannot be fixed in most cases. The reason for them lies in our organism, which tries to initiate the struggle with our tissues or organs. So we cannot stop it. We can, however, introduce hormone replacement therapy, like in case of the thyroid. Sometimes, however, we have no tool, like in the cases of immunological defects in the ovaries. In such cases, even in young patients, we can observe premature ovarian dysfunction and unfortunately, it is always a diagnosis which is verified retrospectively. The only possible decision then is the egg donation program. A lot of immunological problems are associated in different ways with endometrial receptivity directly. If we have the process of pathology in the uterus cavity or other organs, this will have an impact on the progression of the pregnancy. F. e. , if we talk about abnormal thyroid functioning – it leads to high levels of TSH. In some cases, when the TSH level is very high, it provokes miscarriages, causes infertility and, it can provoke great complications of the health of the baby associated with its intellectual development. So, there are many aspects we should take into account. It’s a very wide issue, and it would require a whole new lecture to answer.

This is currently the centre of our scientific research which we started about four years ago. As I said, I work as a tutor as well, in scientific trials at the university clinic, where we started the program for patients with immunological diseases. In general, when we talk about any autoimmunological diseases, the rule of detection and verification of the disease is to detect the antibodies to the tissue. For example, if we talk about the autoimmune disease of the thyroid, we test the blood for the presence of antibodies for thyroid. In the same way, we started to investigate the presence of antibodies to the endometrium. In some cases, especially the high prevalence was observed in patients with endometriosis because of the nature of the disease associated with autoimmune defects. So, in case of the presence of these antibodies, we have observed a high incidence of long-lasting infertility or poor prognosis infertility or multiple ineffective attempts of impregnation. That’s why the second case I presented earlier was associated with this kind of pathology. And as therapy, we have administered a human immunoglobulin to prevent or stabilise the process. We cannot fix it, completely but we can minimise the activity of this process. This therapy was effective so, in some cases, when we have indications (the count of implantation failures, severe autoimmune diseases and processes in the organism) we do these lab tests. I’m not sure if in your countries you have many labs which can perform these tests, because they are usually located in the university clinics, as it requires specific equipment and qualified specialists, so it is not a routine test. However, it is a rare case. Don’t think that this test is recommended for everybody. There are specific indications for it.

For many years, we have heard the opinion that if there are some reproductive problems – the woman is to be blamed. But right now we have a lot of data of correlation of poor prognosis and poor outcomes in couples with severe male factor. The data suggests that we really should talk about this malefactor here. It’s proved, and we have a lot of trials indicating that the age of the man and the quality of sperm has a great impact on the outcome. Even in the egg donation program, when the quality of oocytes is really good, we see that the quantity and quality of embryos differ depending on the quality of sperm. Three years ago, we started to perform pre-implantation genetic testing in the egg donation program. At that time, many physicians told us it was not necessary, because a god donor would always produce good embryos, but it is not true. We have a great number of cycles per year, so my team performs more than seven thousand cycles per year, so it’s a great figure. With the genetic testing, we can see that among four embryos at least one is abnormal in most cases. So the levels and features you have provided concerning sperm quality is an absolute indication for pre-implantation genetic testing. Another thing is that not only the quality of sperm plays a role in the possibility of miscarriage. There is a strong correlation between the level of the DNA fragmentation in sperm with the level of miscarriages. Data from around the world suggests there is an elevated risk of miscarriage due to elevated DNA fragmentation in sperm.

If by in vitro you mean the start of the preparation for embryo transfer we usually do it in the following cycle. We always start by preparing the embryos because this is the most difficult, and unpredictable stage of the whole process. Even in young patients, sometimes because of a malefactor, sometimes because of some individual features, we have some unpleasant surprises during embryo development. We work with biological material, we have to create perfect conditions for embryo development, but unfortunately, we only see the results during the procedure. We cannot make the prognosis for the number of embryos outcome, the quality of embryos outcome, especially in patients with a complicated medical history or advanced age. Therefore, we always start with ovarian stimulation with individualisation of ovarian stimulation and prepare embryos. After pre-implantation genetic testing, when we have a conclusion that we already have enough embryos, we start to prepare the endometrium. That’s why it is better to do it after ovarian stimulation, as during that procedure we have to prescribe a patient some hormones, very slightly but still above the physiological level. If the patient has any pathology of endometrium it may provoke its progression, so it is better to make the therapy and the preparation not before but after ovarian stimulation is very close to the planned embryo transfer. If you need to have an endometrial biopsy – its result and diagnosis will give us the answer as to what kind of therapy you need and the duration of the therapy. In case when the biopsy gives us the result that there is no pathology, and everything is fine, we can make the transfer during the following cycle after the biopsy.