What should we evaluate after failed IVF cycles? How to proceed further?

In this session, Dr Zane Vītiņa, a Gynaecologist Reproductologist, the Director of Clinic EGV, Riga, Latvia, has been discussing various reasons for failed IVF attempts and what can be done to improve your chances.

Before 1st IVF cycle – investigation

Dr Vītiņa started by explaining how important is the investigation done before the first IVF cycle. When it comes to women, the investigation includes an interview. Patients are asked if there were any diseases in the past, also inherited diseases. It’s also important to ask about reproductive function, pregnancies in the past. We ask about when the menstrual cycle started, how regular are they. If there is any specific discharge from the vagina, if there is any discomfort during sexual intercourse, how many partners the lady had and when she started her sexual life. We evaluate hormonal status, especially Anti-Müllerian Hormone (AMH), which gives us an answer on how big a possibility is to get pregnant with the patient’s own eggs.

We evaluate FSH and LH hormones as well as Estradiol, which comes from ovaries. The thyroid gland and all four androgens are also checked. Any disturbances in hormonal status can lead to no-ovulation. We also check if there were any infections in the past, especially Chlamydia. Around 25% of women do not know that they had Chlamydia in the past, there may not be any symptoms, but the tubes can be blocked and closed, and a new tissue can appear in the abdomen. We check for Toxoplasmosis and Rubella IgG. If a woman didn’t have Rubella or she’s not vaccinated, she has to be vaccinated before a planned pregnancy. Toxoplasmosis is an infection that can infect the baby only if the woman was exposed during pregnancy. We perform pap smear and check for infections, especially sexually transmitted infections, not later than three months before stimulation.

When it comes to men, we ask almost the same questions. The andrologist performs an ultrasound examination and evaluates testicles just to be sure that there is no varicocele. We check spermogram, we look at concentration, motility and morphology, this is included in every spermogram.
We also perform an HBA test (hyaluronic binding assay) to check the maturity of sperm cells in fresh semen. MAR (mixed agglutination reaction) tests immunological status, checks for antibodies of the IgG and IgA. The oxidative stress test is the only test that shows whether men should use antioxidants before treatment.

Failed IVF cycle – evaluation

Guidelines say that we need to evaluate everything more in-depth after two failed attempts, especially if there were good quality embryos and good endometrium.
After failed cycles, we use 3/4D ultrasound. Sometimes, we use it before the first cycle, but even if the 2D ultrasound doesn’t show anything after a second failed attempt, we always use the same evaluation, and it is nearly as effective as MRI (magnetic resonance imaging).
Two types of pathologies can occur: congenital and obtained uterine pathologies. The most important for implantation failure, which can be detected with 3D ultrasound, are congenital pathologies.

The uterus and genital tract develop during the 5th-9th week of pregnancy, when a woman is still inside the mother’s uterus. In the beginning, two ducts go together, there are two uteri, afterwards, the middle part that fuses dissolves. A septum can be formed after the two uteri halves join to form a normal uterus but fails. The septum can be very tiny and thin, and with ultrasound, we do not see it, this could affect implantation. If the septum appears, it is very often covered with the endometrium. It could also be a reason why missed abortion occurs.

We perform hysteroscopy for diagnostical aims when we don’t see any pathology with ultrasound. During hysteroscopy, we take a little piece of the endometrium for histological evaluation as well as the microbiome. If we find a problem, we treat it. We can also find polyps, which can be removed during this procedure.

Implantation can fail due to altered timing of the window of implantation (WOI), which we can check with the ERA test (Endometrial Receptivity Array). To achieve pregnancy, we need chromosomally normal embryos and a receptive endometrium. In 30%, the endometrium can be non-receptive. Endometrial Receptivity Window means the time when the embryos can implant. It usually occurs on the 5th day of progesterone, the 5th day after ovulation, it can be changed, though. It usually lasts approximately 24 hours, typically, it is only 8 hours. How do we detect this pathology? We usually prepare a patient for embryo transfer, but when we would normally put the embryo inside the uterus, we take a little piece of the endometrium and evaluate it. The evaluation is based on morphological changes after the progesterone and 238 gene expressions during the period of window receptivity.

The most frequent male reason for failed cycles or absence of blastocyst developing or miscarriages is DNA sperm fragmentation. The major contributing factor for sperm DNA fragmentation is oxidative stress, and it can be associated with:

• infection
• high temperature
• elevated testicular temperature
• recreational drugs
• smoking
• alcohol
• stress
• bad diet
• advanced age
• varicocele

If two embryo transfers fail, it is mandatory to do karyotyping. If the couple is older and would like to be treated with their own genetical material, we perform it before the first attempt. In this situation, it is also mandatory to evaluate Thrombophilia. There can be congenital and obtained Thrombophilia. It is a group of pathological blood coagulation that increases the risk of thrombosis. The smallest vessels are in the placenta.

At the time of pregnancy, first, the implantation may not occur at all. The second thing is that very often pregnancy doesn’t develop further than chemical pregnancy. Thrombophilia can cause infertility, miscarriage, spontaneous abortion, premature delivery, Intrauterine Fetal Death (IUFD), Intrauterine Fetal Growth Retardation (IUFGR), placental abruption, preeclampsia, maternal thrombosis or tromboembolia.

IVF failure – embryo factor

Embryoscope

If in previous cycles Embryoscope, the time-lapse incubator hasn’t been used, we recommend using it after failed cycles. Normally after fertilization, we need to evaluate fertilization after 18 hours, and due to that, we need to take out this embryo from the incubator and evaluate it under the microscope. The embryologists check if there are any crucial problems, however, taking the embryos out can reduce the possibility of live birth.

Blastocyst cultivation

We can transfer a day-2 embryo, which consists of between 2 and 4 cells, day-3 consists of 8 cells, as well as a day-5 embryo which is a blastocyst and consists already of approximately 100 cells. Around the embryo, there is a sort of shell, called zona pellucida. At the end of the day 5-6th, an embryo goes out from this shell and hatches in the endometrial wall.
We can perform the transfer on the 2nd and 3rd day, but it is always better to transfer a day-5 blastocyst.

Assisted hatching

The hatching is happening naturally. However, in some situations, it is mandatory to make a little hole in this shell. This method is called assisted hatching. It increases implantation chances, it can be done via laser, mechanically or chemically, but it is best to use a laser.

PGT-A

Another thing that is recommended if there are failed cycles is to screen the embryos for aneuploidies. It can be done by taking the polar body, one or two cells from a day-3 embryo are taken. However, it is much better to take approximately 10 cells from the blastocyst. PGT-A can help us choose a euploid embryo and transfer only healthy embryos.

PGT-A is indicated in the advanced maternal and paternal age, habitual miscarriages, previous aneuploidy pregnancy, previous failed implantations, and severe sperm pathology.