In our recent event, the panellists discussed several critical factors that can significantly influence the success of IVF treatment. The key points they covered were women’s age, embryo quality, uterine health, genetic factors and more.
Featuring Experts:
Dr Lenka Hromadová – Chief Medical Officer and Head of IVF at Repromeda, The Czech Republic
Dr Federica Moffa, MD, PhD – Medical Director of Fertilab, Spain
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH – Partner at Hygeia IVF and MITERA Hospital; Head of Southeastern Fertility Solutions, Greece
The event was hosted by: Dr Alan Thornhill, Fertility Expert & Coach; Founder of The Fertility Guy
Dr Lenka Hromadová, Repromeda: Yes, I guess that adenomyosis can be the reason for the implantation failure. So, if the patient has already started the treatment, I would recommend continuing. According to my opinion, I would recommend using Zoladex or another agonist for about three months at least.
Dr Federica Moffa, MD, PhD, Fertilab: I think we have evidence that in some patients, a natural cycle for embryo transfer, especially in patients with adenomyosis, can reduce the need for hormone replacement treatment. If the patient is losing weight, her cycle and period will be more regular, and we can try the natural cycle. Having a BMI below 30 in general can help with implantation.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: Yes, the first question that arises is how regular the cycle of the patient is. The second question is the possibility of combining with PCOS. By losing weight, even up to 10%, the possibility of the patient having a regular cycle is higher. If we start with the stimulation, regardless of the medication used, the results are likely to be better in terms of both the number and quality of the oocytes.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: It depends on the TSH value. If the TSH is around one, it’s fine, and we could proceed with the embryo transfer. In our clinic, according to our experience, we also give the patients selenium and ProLon 5 mg tablets once daily. Hashimoto’s is an autoimmune disease, so by considering this and giving corticosteroids even in low doses, we can help with implantation.
Dr Federica Moffa, MD, PhD, Fertilab: Especially in patients with an autoimmune disease like Hashimoto’s, we know that artificial preparation for embryo transfer, such as using estrogens, can increase the level of TSH. When applicable, if the patient has a regular period, we use the natural cycle as the first-line preparation. Even in egg recipients, we use natural cycle preparation to reduce miscarriage risk.
Dr Lenka Hromadová, Repromeda: I absolutely agree that the natural cycle is the best option for the patient. We don’t use prednisolone very often because we believe it can be harmful to embryo implantation due to its direct impact on the immune system in the womb. The TSH should be kept within normal ranges.
Dr Federica Moffa, MD, PhD, Fertilab: There is no influence on implantation rates based on the donor’s blood type. The only situation where blood group matching is necessary is when the recipient is O Negative, to ensure she doesn’t have irregular antibodies. Otherwise, blood type has no impact on implantation success rate.
Dr Federica Moffa, MD, PhD, Fertilab: This is an open debate, but the evidence is not strong enough to warrant blood group matching based on this variable. In our program, we don’t match blood groups for this reason.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I always perform a blood test because it helps me understand how the implantation has progressed. We usually perform the blood test 9 days after a blastocyst transfer. For a day 3 embryo transfer, which is less common, we perform the blood test on day 11. The value of HCG can also help predict the progression of implantation. In Greece, we can transfer two embryos, so the HCG value also depends on the number of embryos transferred. This is why a blood test on a specific day is crucial.
Dr Federica Moffa, MD, PhD, Fertilab: When we do PGT-A, we biopsy 4 or 5 cells and receive genetic test results. A chaotic result suggests significant genetic abnormalities and should always be retested because the result can vary. We typically thaw the embryos, re-biopsy, and sometimes find that the embryos are normal after retesting.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I would refrain from transferring a chaotic embryo. Retesting is crucial, and if the result comes back normal, I would then consider the transfer.
Dr Lenka Hromadová, Repromeda: We generally don’t retest embryos with multiple chromosome abnormalities. Our genetic lab categorizes embryos as euploid, aneuploid, mosaic, or with segmental aneuploidy. If an embryo shows multiple chromosome abnormalities, we don’t retest it.
Dr Federica Moffa, MD, PhD, Fertilab: The term “chaotic embryo” often indicates significant genetic abnormalities, making interpretation difficult. When PGT-A results are chaotic, retesting the embryo can sometimes yield different outcomes. Thawing and re-biopsying these embryos is a potential approach, as some embryos initially deemed chaotic might actually be normal.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I would avoid transferring a chaotic embryo without retesting. If the rebiopsy results are normal, the embryo can be considered for transfer.
Dr Lenka Hromadová, Repromeda: Our lab categorizes embryos as euploid, aneuploid, mosaic, or with segmental aneuploidy. Multiple chromosome abnormalities usually indicate an embryo is not suitable for retesting or transfer.
Dr Lenka Hromadová, Repromeda: The decision to switch to egg donation depends heavily on age. For younger women, further testing to identify underlying issues like uterine abnormalities, coagulation disorders, immune system disorders, and microbiome imbalances is advisable. For women over 40, egg donation might be recommended due to diminished egg quality with age. Regardless of age, if PGTA hasn’t been performed, it’s worth considering to rule out genetic issues as a cause of implantation failure or miscarriage.
Dr Federica Moffa, MD, PhD, Fertilab: Addressing the male factor is also crucial, especially if considering egg donation. It’s important to investigate the male partner’s sperm quality thoroughly. Sometimes, couples turn to egg donation without adequately evaluating the male factor, leading to suboptimal results even with donor eggs. Ensuring the sperm is healthy is vital, as it significantly impacts embryo quality and success rates.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: If she was using her own eggs originally, she would need to repeat hormone tests, especially the anti-Mullerian hormone (AMH) every six months to plan stimulation and decide on the protocol. For egg donation, we need to check for hepatitis, HIV, syphilis, etc., and thrombophilia screening, especially if she had negative results in the past. This helps identify any other factors leading to implantation failure. Whether you need to repeat them or not depends on the past results. If there was a positive thrombophilia screening, treatment with heparin and low-dose aspirin would be necessary. It really depends on the results themselves.
Dr Federica Moffa, MD, PhD, Fertilab: It also depends on the legislation. In Spain, for a new fertilization treatment, even with an egg donor, the recipient has to repeat infectious disease tests like hepatitis and HIV.
Dr Lenka Hromadová, Repromeda: I usually check AMH level and antral follicle count (AFC). Even if AMH is low, but there are more antral follicles (e.g., 6-10), I recommend a short antagonist protocol with a higher dose of gonadotropins (FSH plus LH), up to 450 units. If the AFC is low, I decrease the dose to 250–300 units, as higher doses don’t make sense without sufficient antral follicles.
Dr Federica Moffa, MD, PhD, Fertilab: It’s challenging to stimulate poor responders. If the follicular phase is short, we use estrogen priming in the luteal phase of the previous cycle. We also apply strategies like Dual Stimulation and double trigger for ovulation induction. In some patients, we revert to the long protocol with GnRH agonist from the mid-luteal phase of the previous cycle to avoid early recruitment of the dominant follicle.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: We use mild IVF with 150 units daily in an antagonist protocol, sometimes adding clomiphene or letrozole. The goal is to retrieve a small number of good-quality eggs. We avoid the long protocol.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: High doses are now out of fashion due to cost, safety, and efficacy concerns.
Dr Federica Moffa, MD, PhD, Fertilab: I would love to have this patient in my clinic. With three 4AA and one 2AB embryo, the overall life birth rate is around 80%. Assuming no other problems, the chances of a live birth are high, especially with single embryo transfer.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: This question is similar to the previous one, but I’d like to share our experience in Greece. In Greece, IVF treatment with egg donation is allowed until the age of 54 under specific conditions, including breast screening, cardiological screening, etc. Last year, we performed 77 embryo transfers for women between 50 and 54 with a pregnancy rate (positive hCG test) of over 60%. This shows the importance of donor egg quality. Regardless of the recipient’s age, if the uterus looks normal and the endometrium is appropriately prepared, pregnancy can be achieved.
Dr Federica Moffa, MD, PhD, Fertilab: In Spain, there is no legal age limit for egg donation. However, recipients should be healthy and have a low obstetric risk of complications. In our clinic, we set a limit of 50, with some exceptions up to 51, for instance, if the patient already had a pregnancy and still has a frozen embryo. But we try to stick with 51 as the maximum. This is because of the risk of complications. We know there’s a higher risk of premature delivery, preeclampsia, and other complications. We may adjust these limits more overtime, but for now, we consider these risks significant.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: We are waiting for the baby take-home rate. As I mentioned, we had this high age limit only for the past two years, so we are also waiting for the results from all clinics to determine how safe a pregnancy at this age is.
Dr Lenka Hromadová, Repromeda: In the Czech Republic, there is a limit of 49 years for both IVF with own eggs or donated eggs.
Dr Federica Moffa, MD, PhD, Fertilab: If a 40-year-old patient is transferring a blastocyst with her own egg and then has a miscarriage, stress has a minimal impact. We have to assume that chromosomal abnormalities are the main cause of the miscarriage. The impact of stress is very little in this case.
Dr Lenka Hromadová, Repromeda: For more than 10 years, we have been transferring only one embryo. Our priority is to ensure the birth of a healthy child. Transferring more than one embryo increases the probability of multiple pregnancies, which carry a high risk of premature birth and associated complications. Babies born prematurely can be seriously ill and may even die due to prematurity. Multiple pregnancies also pose significant risks to the pregnant woman, including conditions like preeclampsia, high blood pressure, and diabetes.
Dr Federica Moffa, MD, PhD, Fertilab: In Spain, more than 90% of transfers are single embryo transfers. In our clinic, we have 97% single embryo transfers, regardless of whether it’s IVF with own eggs or egg donation.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: It’s at least 60%. However, when we have older patients, 42 or 43, using their own eggs, we may go for a double embryo transfer. It depends on the patient’s age.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: Some clinics or doctors measure progesterone levels, but I don’t. I provide both vaginal and subcutaneous progesterone. Some doctors say we need at least a level of 12 to ensure sufficient progesterone.
Dr Federica Moffa, MD, PhD, Fertilab: We always test progesterone levels before transfer. If it’s below 12, we add subcutaneous progesterone. It depends if it’s a natural cycle, where the patient produces progesterone herself due to ovulation, or an artificial cycle. We find more cycles need supplementation with subcutaneous progesterone in artificial cycles. We also test progesterone levels on the day of the pregnancy test with beta hCG. If it’s below 14, we add supplementation. Studies, especially from Elena Labarta – Fertility Specialist at IVI group, show it’s crucial to maintain good progesterone levels during the implantation window and early pregnancy to reduce miscarriage rates.
Dr Lenka Hromadová, Repromeda: It is crucial to ensure adequate progesterone levels, as previously discussed. If there are coagulation disorders, I recommend using low molecular-weight heparin. Prenatal vitamins, including folic acid, are important. Myoinositol can also be beneficial. However, these recommendations can be very individual. Knowing more about the patient would allow for more tailored advice.
Dr Federica Moffa, MD, PhD, Fertilab: I agree with Dr Lenka. Ensuring adequate progesterone levels is critical. For patients with known issues, such as coagulation disorders, low molecular weight heparin is often recommended. Prenatal vitamins, particularly those containing folic acid and sometimes vitamin D, are generally advised.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: Adding to that, maintaining a healthy lifestyle is important—a balanced diet, moderate exercise, and avoiding stress. Avoiding smoking and alcohol is also critical. These general health measures can support a successful pregnancy post-embryo transfer.
Dr Lenka Hromadová, Repromeda: Usually, we perform embryo transfers even in patients who take antidepressant medication, but it depends on the recommendation of the psychiatrist. We ask for a recommendation from the psychiatric specialist because the doctor knows the health status of the woman very well. It depends on the specialist’s recommendation, but the medication can be used even during pregnancy.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: It depends on the number of available embryos. If we have more than four embryos on day three that are of good quality, we go until day five. If the number of available embryos is lower, we would consider a day three embryo transfer. When we have the consultation with our embryologist, we perform the embryo transfer on day three and leave the rest of the embryos in the culture medium until day five, and then we decide if we freeze them or not.
Dr Federica Moffa, MD, PhD, Fertilab: We do perform a lot of PGT-A, so in the rare case where we just have 1 embryo, and we know that the patient will not go for PGT-A, we may discuss it with the patient. But I don’t remember the last time I transferred on day 3. There is room for day three sometimes, and different clinics have different philosophies. However, it’s becoming very rare. In own egg IVF cycles, we perform over 36–37 cycles mainly with PGT-A, so there is a very small number of day 3 transfers.
Dr Federica Moffa, MD, PhD, Fertilab: I would prefer to go to blastocyst if we have four day 3 embryos, especially at age 43. There are studies suggesting that the crosstalk between the uterus and abnormal embryos can alter the receptivity of the endometrium. If we have abnormal embryos, they may affect the signals to the endometrium and impact the receptivity for the good one.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I perform double embryo transfers, but when patients ask if one embryo affects the other, I admit that I don’t think so. The truth is, we don’t know for sure.
Dr Lenka Hromadová, Repromeda: At age 43, with a very poor ovarian reserve, the chance is very low. The quality of eggs will be, unfortunately, very low. In this case, I would recommend considering egg donation.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: When I have such an experience with a patient, I ask myself about the egg quality and how the poor quality has led to such a result. I try to change the protocol. Since we don’t have any information about the protocol or medication this patient received, I would change the medication and go for another stimulation. She mentions that she has a relatively appropriate number of eggs collected, so I think she deserves one more chance, but I would change the stimulation protocol.
Dr Federica Moffa, MD, PhD, Fertilab: There seems to be evidence that a healthy microbiota with a predominance of lactobacillus around 90% is the best. Studies compare the fertile population with the infertile population, showing differences. It seems important, but sometimes it’s difficult to reach this 90% with treatments. We give oral and vaginal lactobacillus and probiotics. In our clinics, we test the microbiota in case of failure, not as a first-line diagnosis. It’s important to try to correct this and reach a better rate of lactobacillus presence. However, stating that 90% is strictly the limit is not certain today.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I would go for another stimulation to ensure a higher number of euploid embryos and perform a frozen embryo transfer later. I wouldn’t lose time since this patient is in an advanced age and I don’t want to delay the stimulation. The sooner we get the embryos, the better the outcome of the treatment. So, I would repeat the stimulation, go for the next biopsy with more embryos, and then decide on a frozen embryo transfer after the results.
Dr Lenka Hromadová, Repromeda: From about 8 to 12 months. If the C-section is okay and the ultrasound of the uterus shows a normal picture with no thinner uterine wall, this should be a safe period.
Dr Lenka Hromadová, Repromeda: Unfortunately, it is not possible to use sperm from a deceased husband, even if all consents are in place. If embryos already exist, we cannot transfer them after the death of the man.
Dr Federica Moffa, MD, PhD, Fertilab: In Spain, it is possible to use sperm or embryos, but you need the previous consent of the couple. The couple must sign a consent form allowing the partner to use the sperm or embryos within 12 months after the death. The widow should decide to undergo the treatment within 12 months after the death.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: In Greece, we also need the consent of the couple through a notary. If there is no consent, we are not allowed to use either sperm or embryos.
Dr Lenka Hromadová, Repromeda: Unfortunately, none of these embryos are top quality, but they still have a chance to implant. Top-quality embryos are usually graded 5AA. Even though BB-quality embryos are not as high, they still have a good chance to implant, though not as high as AA embryos.
Dr Federica Moffa, MD, PhD, Fertilab: In my clinic, I would still be optimistic about a 5BB embryo. Given that you are 30 and have 5 embryos, with good cell numbers on day 3, the overall chance of delivery in this cycle is around 80%.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: It depends on the FSH level on cycle day two or three. We no longer use contraceptive pills for preparation before stimulation, as studies have shown that they can affect implantation rates and ovarian response. We perform an FSH test on day two. If the FSH level is under, for example, 10 (for patients under 35) or under 50 (for older patients), we are ready to perform stimulation.
Dr Federica Moffa, MD, PhD, Fertilab: The microbiota is very diverse, and I’m not aware of a direct relationship between Fusobacteria and endometriosis. There is increasing evidence suggesting that endometriosis might involve altered microbiota, but it’s not clear if Fusobacteria specifically plays a role.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: It might be more relevant to consider endometritis rather than endometriosis. Altered microbiota can affect the lactobacillus population and potentially lead to chronic endometritis, which can alter receptivity.
Dr Lenka Hromadová, Repromeda: We use artificial intelligence in our embryological lab. We started quite recently, several months ago. I believe it can help our embryologists, but the embryologist is still the best at assessing embryo quality.
Dr Federica Moffa, MD, PhD, Fertilab: So far, we don’t use artificial intelligence. We use time-lapse to select embryos and consider various parameters, but we don’t apply AI algorithms. We are planning to start in 2025, and I think it will be helpful in the future.
Dr Ioannis Zervomanolakis, MD, PhD, MBA, MPH, Southeastern Fertility Solutions: I am a fan of artificial intelligence. I believe AI is the future. We are setting up a collaboration with a company based outside Greece regarding AI. I think that the subjective opinions of embryologists regarding embryo morphology will eventually be replaced by AI platforms. I look forward to working on it.
Prof. Dr Ana Teresa Almeida Santos, Eugin: I’m a professor at the University of Coimbra and responsible for Eugin Coimbra, Portugal. We are a fertility clinic that is well known in Europe, but in Coimbra, we have only been operating for 1 year. I have been doing reproductive medicine for 30 years now, and we have the particularity of doing a lot of egg donation with non-anonymous donors, which is not very common in Europe. We specialize in this type of treatment.
I think the most important determinant for several IVF attempts is the age of the woman because it is the main influence on the quality of the eggs and the embryos. Nothing is more important than age. That’s why when we have several failed IVF cycles, even with our eggs, we must try to get the option of donation into discussion.
Dr Miguel Ángel Checa, Fertty: As Dr Santos says, age is the most important determinant for the success rate of IVF. When we are 37 years old, we always work with PGT-A. Why? Because it’s important to transfer a healthy embryo. Trying to make failed attempts or attempts that are going to result in miscarriage doesn’t have space in our clinic. For a woman of 45 years, if we do 3 attempts without a pregnancy, probably the next step, in most cases, is going to be egg donation. Normally, after 3 attempts in a 45-year-old, if we don’t have a pregnancy, the best option is to switch to egg donation.
Dr Violeta Fodina, PhD, IVF Riga: The answer to this question is that pregnancy results depend not only on embryo quality. It is a big revolution that we can test the embryos before transfer, and we are happy about it, but the results also depend on other factors. One of them is the status of the uterus and how well it is prepared for implantation. The second factor is the overall condition of the mother’s body, such as coagulation options, hormonal balance, and immunological factors, which can affect the outcome. If this patient has already had such a long experience with unsuccessful treatment, I would recommend focusing on these aspects.
What can we do? First of all, we should examine the uterus. It is a conventional question of yes or no, but maybe we can test the endometrium for implantation possibilities. This includes the timing of implantation, the activity of the endometrium, and the microbiome, which can influence unsuccessful results if there are issues.
Secondly, we need to rule out hereditary and non-hereditary thrombophilia and hormonal factors. Also, very rarely, there are Factor VIII and IX blood issues. One of the controversial options, but one we are starting to use more in our practice, is checking the immunologic status of the patient. Soon, I plan to publish a paper about the Lymphocyte Immunization Therapy (LIT) procedure. We have collected enough experience in this area. It involves extracting white blood cells from the prospective father. The blood sample is then examined and a concentrated solution of white blood cells is then injected into the prospective mother using a series of shallow injections into the forearms.
Follow the medical journals, and you may have the chance to read about this very soon.
Prof. Dr Ana Teresa Almeida Santos, Eugin: The first thing I would say is that in Portugal, it is not allowed to do IVF over 50, and this has a reason, —because of the risks of pregnancies in women over 50. This patient must be aware of the higher risks of pregnancy at that age. Once she is aware of that, she must try to find a centre in a country where it is allowed to do so and where egg donation is done with quality. The donors should be screened for infections and more frequent genetic diseases. This is what I would say to her because the treatment is the same everywhere. IVF is not very different from one lab to another. The main question would be the kind of gametes she will use and the main risks of pregnancy at this age.
In younger patients, we would have to check if the uterus is okay, if there are no problems in the uterus if the endometrium grows as it should, and if there are no other pathologies—like cardiac pathology or any heart issues—that would be dangerous for pregnancy. In Portugal, it would be mandatory to do a screening for heart disease and a general checkup to ensure everything is okay for her to get pregnant, and not to worsen any hidden pathology that she may have.
Dr Violeta Fodina, PhD, IVF Riga: My favourite question. When I get patients over 40, and we start discussing the possibility of pregnancy, I usually begin with one of the criteria we use every day during patient consultations: the Poseidon criteria. I explain to my patients that the results of the treatment will depend, first of all, on ovarian reserve, which we check through the Bologna criteria. This involves 3 points: AMH, FSH, and AFC. When we know how many eggs we can get, we can recalculate the possible chances through the Poseidon criteria.
The results are different for a patient in her 40s with approximately 15 eggs after retrieval compared to a patient with only 2 eggs after retrieval. It’s also important to consider the number of euploid embryos we can expect from a woman over 40. There was a very interesting publication in Fertility and Sterility showing exactly what percentage of euploid embryos we can get from patients of different ages. For women over 40, they calculated for ages 40, 41, 42, and 43, and started with 20%.
Logically, we understand that if we get 10 blastocysts, the chances of getting a normal embryo are pretty high, and the chances of pregnancy are pretty high. But if we have a low response at this age, unfortunately, the percentage is not so high. To finalize my answer, the average chance for a woman over 40 to get pregnant is around 15-20%.
Dr Violeta Fodina, PhD, IVF Riga: I think that the patient has been examined very well, and if we know what is wrong, it’s easier to manage these factors. The Factor V Leiden mutation—this is a thrombophilia, it’s nothing special. So, we will be using microheparin to compensate for these factors.
If we speak about the KIR AA, we are focused on these questions. Our previous strategy and tactic involved comparing the examination of embryos for the KIR receptors. Now, we use a different tactic by utilizing the LED procedure for this patient. Patients with KIR AA, which are hereditary changes in the NK cells, unfortunately, have a higher risk for non-implantation or early miscarriages. Even if we succeed, there’s still a risk of placenta issues in the third trimester of pregnancy.
If we know these factors, in my opinion, they should be addressed during the preparation time, and this woman will have the same chances as any other woman over 40. I will focus more on the ovarian reserve and the possibility of getting good embryos.
Dr Miguel Ángel Checa, Fertty: I want to reassure patients not to be scared. Now, over the last year, many papers have been published showing that this mismatching is not an incompatibility. It’s only a mismatch. When you have HLA-C2C2, this mismatching still allows for pregnancy—it’s not implantation failure. You only have a higher risk of miscarriages and preeclampsia.
There are many published papers—not from us, but from others in reproductive medicine—about thousands of deliveries with this genotype, with a higher risk of hypertension but successful deliveries. Before starting treatment and focusing on immunology determinations, I think it’s not the right approach. Over-diagnosing and delaying IVF in patients who don’t have previous failures or miscarriages isn’t helpful. We need to be serious because recognizing these determinations doesn’t significantly increase pregnancy chances in most patients.
It’s like the determination of endometrial receptivity. Years ago, we started practising this test for many patients, and I researched and published papers on it. But trying to use it for all patients is not a good tool. The top clinics in Spain, like IVI Clinic and other clinics, have recommended not generalizing these tests because often we are unnecessarily changing protocols.
3 years ago, we started shifting towards a natural cycle for embryo transfers, and the chances of pregnancy were equal or superior compared to using hormonal replacement therapy. People must understand this. Many companies commercialize these tests directly to patients, which is not good because they don’t know how to determine if the test applies to their case or not. These tests should be restricted to those with serious issues like recurrent implantation failure or more than three miscarriages.
You know, with good embryos, regardless of age, after two or three transfers, the pregnancy success rate is nearly 100%—95%. If you have a good clinic with a strong culture system, after two transfers under 35 or three transfers over 40, you could achieve pregnancy. We are doing too many tests for the 5% of cases where chances are low. For the other 95%, we can achieve pregnancy with good embryos, so we need to focus on obtaining good embryos to ensure success.
We have a law since 2006, a very liberal law. You will be surprised, but in our law, we don’t have a limitation on the age of the woman. But of course, we have our own clinic rules. I agree with my colleagues from Portugal—I am also very sceptical about pregnancy after 50. This brings a lot of risks for the woman during pregnancy, such as gestational diabetes, placenta abruptions, arterial hypertension, and different complications for both the mother and the future child. These risks are pretty high.
If we speak about egg donation, I’ve answered that question. But if we speak about using one’s own eggs, of course, we try to do the maximum we can. However, we are not gods, and we don’t have magic tablets to change the age of the egg. My personal opinion is that we need to focus on analyzing each patient before we start IVF treatment. If we see that the chances are pretty low, we need to explain that to the patient and give a realistic picture. I hope I answered the question.
Dr Miguel Ángel Checa, Fertty: In Spain, there’s a recommendation—not a law—that we don’t go past 50 years for IVF. Our clinic restricts treatments after 50 years. Based on my ethics and the decision of all clinicians here, we don’t go past 50 years in IVF. After several years of practising IVF, we haven’t obtained any pregnancies over 45 years old. So now, we restrict patients from undergoing IVF over 45, because we simply don’t get results. We are a serious clinic, and we don’t want to give false hope to patients for treatments that don’t yield results.
