What to do after failed cycles and miscarriages?

Dealing with failed fertility cycles and miscarriages can be emotionally challenging. Watch the webinar led by Dr Alexandra Eissler, Fertility Specialist at IVF-Life Alicante, who provided helpful information on the next steps after facing failed cycles and miscarriages and how they can be prevented.

The importance of diagnostic evaluation

Before starting any treatment, it’s essential to find the cause of infertility, why miscarriages are happening, and why implantation is not occurring. We want to discover this before attempting another treatment because there may have been previous treatments in other clinics, and we can learn from them. We can learn from every failed cycle, implantation, or miscarriage, but we have to study them and understand what happened.

There are various reasons for treatment failure, with the most important ones being egg quality, the uterine lining, and male factors. There are other reasons as well that will be addressed later on.

Evaluating egg quality and quantity

Egg quality is crucial in the treatment process. We need to have an adequate number of eggs, and ovarian reserve decreases with age, so this is an individual consideration. We also measure the Anti-Müllerian hormone (AMH) level in the blood to understand the ovarian reserve better. Additionally, the number of follicles in a scan is counted to assess the cycle. Age is essential, not only for the number of eggs but also for their quality, as older patients may have a higher risk of chromosomal abnormalities in embryos.

To address issues with egg quality, we can consider various options. Individualized priming may be necessary for patients who need more time to develop eggs. Pre-implantation genetic testing of embryos can be performed to check if embryos have the correct number of chromosomes. Other genetic tests for specific conditions can also be considered. Personalized stimulation protocols can be developed based on past treatment experiences. Platelet-rich plasma (PRP) treatment is a new method that has shown promising results in improving egg quality and quantity.

In the end, we need to decide whether IVF is the right treatment or if egg donation might be a better option. This decision should be made in consultation with the patient, considering the advantages and disadvantages.

Optimizing the uterine lining

The uterine lining is a dynamic tissue that changes regularly. There are several factors we can consider, to improve the chances of successful implantation. We can test the implantation window to ensure the lining is at its most receptive state. Immunology is also crucial, as the body has natural defense mechanisms. We test for natural killer cells, T-helper cells, and their ratios. We can treat any issues found in these tests with medication. Testing for endometritis, a chronic inflammation of the endometrium, is also essential, as it can be bacterial or non-bacterial. This can be treated with antibiotics if necessary.”

To determine these factors, we conduct an endometrial biopsy, a relatively painless procedure done without anesthesia in most cases. It’s done in our consulting room, and we analyze the tissue to get more information about the lining’s condition. In some cases, it might be necessary to consider going a little further and testing for receptors, as well as HLA-C genotyping. However, this is reserved for special cases and needs to be considered individually.

Exploring male factor and sperm quality

Let’s take a closer look at the male factor. The male factor primarily concerns sperm quality, and there can be various issues associated with it. I’ve listed a few potential diagnoses that can result from a spermogram. In simpler terms, it can involve having too few sperm cells in the sample, reduced mobility, abnormal forms that make it challenging to find normal sperm cells, or even a complete absence of sperm cells in the sample. In such cases, we need to investigate whether it’s due to an obstructive or other factors.

These issues can be directly observed in the sperm sample. Additionally, we examine sperm DNA fragmentation to identify potential problems with DNA destruction and assess apoptosis to determine how many sperm cells are self-destructing after ejaculation. Various mechanisms can influence sperm quality, and we can offer medications and vitamins to improve it. If these measures don’t suffice, testicular sperm aspiration (TESA) might be an option. TESA involves puncturing the testicle to obtain higher-quality sperm cells because sperm can encounter oxidative stress during their journey out of the testicle, potentially damaging them.

The quality of sperm is crucial for fertilization. Different techniques are used, such as IVF, IUI, IMSI, or PICSI. The choice of technique depends on the laboratory’s evaluation and the specific situation.

Investigating other causes

Miscarriages, implantation failures, or cycle failures can have other causes. To address these issues, we may examine your karyotype, assess chromosome abnormalities, and investigate immunological factors, thyroid health, and autoimmune diagnoses. Circulation and thrombosis risks are also assessed to ensure a safe pregnancy.

Before starting treatment, we evaluate the best individual approach based on various tests and diagnoses. Typically, treatment begins with ovarian stimulation or preparation for embryo transfer, depending on the selected treatment plan. We provide guidance on medication, dosages, and schedules, customized to your needs and test results.

Once the embryos are obtained, we proceed with embryo transfer. This process requires specific preparation, and we might conduct an endometrial biopsy or a mock cycle to optimize the uterine lining for implantation. We follow up until the end of the first trimester, monitoring progesterone levels and providing guidance on post-transfer medication.

For the actual embryo transfer, it’s advisable to arrive a day before and stay for a day afterward to minimize stress. We provide all the results and support you in the initial weeks of pregnancy, as well as during the follow-up after treatment. In conclusion, the treatment process and cycle analysis are highly individual and tailored to each case to address underlying issues and improve the chances of success in subsequent attempts.