In this webinar, Maria Arqué, MD, International Medical Director at Fertty International, is explaining IVF add-on procedures and their impact on the outcome of treatment.
I know it is a very difficult situation whenever you are getting contradictory information from different doctors. I don’t know your specific case. I don’t know if the previous treatment was also with an egg donor or not. The truth is that usually in most of the cases when we do the endometrial receptivity test, in more than 70-75 % of the cases the endometrium is going to be receptive. Probably it won’t change anything. The protocol that we need to use, a good progesterone, everything will be the same.
Having said that, after having had 5 failed cycles, if there is any suspicion that maybe there can be issues with the endometrium receptivity, I think that it would be worth making sure that there are no problems there because you have already spent a lot of time and money on fertility treatments. Probably having the reassurance that there are no alterations in the window of implantation, can give you a little bit more clarity on how your treatment is going. Imagine the worst-case scenario, if during your next transfer the embryo doesn’t implant and you have not done the test, will you have regrets or will you be wondering if your window of implantation was misplaced? Maybe we should have a different dose of progesterone. That’s the only thing but the chances of obtaining normal window of implantation are more than 70%. I wish I had a clear response to that but it’s not black and white it’s a gray area. Probably after having done so many IVF attempts, I would check if there is anything else that can be an issue.
It looks like they can have a beneficial effect on the likelihood of implantation but that’s not that clear. The evidence that we have is not good. Having said that, there is a lot of media that don’t have those names and the labs already use them routinely so sometimes there’s no need to pay extra money if the media which the lab is using already contains similar compounds. I wish I could give you more specific numbers or the reason so I’m sorry that I cannot give you more information about that. This is one more add-on to the treatment and it might have a beneficial effect but it’s not clear.
First of all, I don’t recommend add-ons at all because I don’t think that we can generalize in that case. I think that it really depends on each case. The most important thing is that we’re going to look at the patient. Having said that, also the prognosis in specific case then we can decide if there any add-ons that might be beneficial in their specific case and what benefit can bring for a specific patient. I cannot give a general recommendation.
So as far as I’m concerned, a DHEA would only be indicated for patients who have low ovarian reserve. I am not aware of any reliable data published in any of the reliable papers of reproductive medicine stating that DHEA can help with recurrent miscarriage. So I would not recommend it.
Basically, one of the main reasons why aspirin is added to cycles is in the context of patients that have recurrent miscarriages, thrombophilia or even patients who do not have thrombophilia but had all the assessment of the recurrent pregnancy loss and recurrent implantation failure done and all the tests were normal. So aspirin may play a role in helping even though it’s an empirical treatment which means that we don’t have the data to verify that this is going to have a positive effect but, from the clinical experience we see that sometimes in this kind of population that might be helping.
Antioxidants are supplements. The oxidative stress that our bodies are exposed to depends on several different factors and some of the most important factors would be our general stress, our lifestyle, and diet. If you’re having already a very healthy lifestyle and diet and still your test results are not good, e.g. sperm quality is not good, probably you would be benefiting from taking antioxidants. Otherwise, I think that it’s much more important to focus on changing the lifestyle habits. If the patient smokes and takes antioxidants, that’s going to help partially to cope with the oxidative stress they are exposed to but it is going to be much more beneficial for them to quit smoking rather than taking the supplements and smoking 20 cigarettes a day.
A lot of times things can be much cheaper than what we think and the solutions that are the better ones require more effort from us. Changing our lifestyle, having healthy diet, not smoking, not drinking or drinking very occasionally, having a normal BMI, trying to cope well with stress, having some stress management tools like yoga, meditation or whatever might work for you. If you can, avoid any processed foods, sugary drinks and all similar things. Try to have a very good sleep and rest. Those are the things that help you cope with oxidative stress much more than the antioxidants. Here, I’m speaking all the time about men because it’s only with males that we have the evidence of improving the sperm quality and, at least, we’ve seen it might work for males that have some alterations in the sperm. We’re seeing that it may increase birth rates when man is taking antioxidants.
ERA test stands for Endometrial Receptivity Array test. It’s a test which is done as part of endometrium preparation. When you are about to have your embryo transfer and receive the eggs from an egg donor which means that you have already been taking some estrogens for a while, progesterone, we would do a biopsy of the endometrium and your receptivity would be assessed. There are several good tests that assess only the receptivity, there are other ones that would assess the receptivity, also the microbiota and immunology profile. With all that information we can see if there are any alterations but, specifically speaking, we find out more about receptivity. The window of implantation has a very specific time and for a very small population of patients it can be displaced. With this test we could identify if the patient’s window of implantation is a little bit earlier or a little bit later than what we thought before. As I mentioned before, 70-75% of patients will have normal receptivity and we can identify 25-30% of patients that might have a displaced window of implantation and might benefit from having more days of hormone stimulation.
Regarding the ERA test, I would not recommend it from the very beginning for patients who are just starting their fertility treatment. I’d recommend to do it in the context of someone who has had several failed embryo transfers with very good quality blastocysts. It would help if you had the information if they were chromosomally normal but the embryos did not implant. I’d recommend it also in case where there are no other problems with the lining, e.g. there is no very thin lining that might justify why the embryos didn’t implant. That would be the indication to do the ERA test. More than three embryo transfers which in total should be more than four euploid blastocysts that didn’t implant after having done an endometrial preparation. That’s the context in which we could consider doing that and even in that context, we’re going to find 70% of patients are OK.
There is a lot of different brands. ERA test is one of the most known ones as endometrial receptivity tests have different names. Sometimes when we do the biopsy we’re checking not only the receptivity but also checking if there’s an infection, immunology issues or microbiota. So it is difficult to know exactly if that was the same test or not.
In a lot of clinics assisted hatching is used for patients that are using frozen embryos and because there was some data from some small studies saying that when we freeze the embryos, their zona pellucida, which is the shell that protects the embryo, can harden and maybe in that context assisted hatching would be beneficial. It’s not that clear and as I said it doesn’t look like it increases the live birth rate so probably it’s not necessary unless we see in a specific case that the zona is very hard, so then there is an indication. But it has not been proven to give high birth rates. You need to discuss it specifically with your doctor and your biologists to see whether there are any indications in your specific case, why they think that it might be beneficial and if it is going to impact your live birth rate.
I have a lot of patients taking Q10 and fish oil when they are doing the cycle. Q10 is a very potent antioxidant and it has a very important role in cardiac medicine. There are some very small, very low-quality evidence saying that maybe it can help with quality but it’s not proven. I don’t think that this is going to make any harm to take Q10 but again it’s a treatment that is expensive so I cannot go against it. I don’t think that it’s going to harm you but we don’t have proof or a certainty to say that it’s going to be beneficial.
Vitamin E and fish oil really are beneficial because you will be improving your omega-3 intake which is something absolutely beneficial for successful outcomes, both for pregnancy in general but also for ART. Chinese medicine is a very broad term, it may be seen as herbs, and I don’t have the knowledge about Chinese medicine to let you know that. In general, what I would say is I would not mix that or if you are going to use some specific Chinese medicine during your cycle, you should be very specific about what you are using and discuss that with your doctor and make sure that this is not going to interfere with the cycle.
Even though with IMSI we’re looking at the sperm through the microscope and we can assess what is inside the sperm, it looks like there are no differences in terms of traits. It is true that there are some papers saying that it looks like using IMSI might decrease the miscarriage rate but in terms of IP and having a healthy baby didn’t look like it was an important difference. I generally think that it’s not necessary to do IMSI but obviously it has to be individualized and checked with your doctor. It is worth checking to see why that might be integrated into the case, why it might be useful, and which other benefits would that bring to your treatment.
I absolutely, 100%, recommend getting an ultrasound of the uterus and the ovaries before the IVF treatment. Those two are the mandatory tests for my patients and I am pretty sure that all, if not the vast majority of doctors that are also giving webinars on MyIVFanswers platform or work in other clinics, recommend it, too. This is like the basic information that we need in order to decide what is the best treatment protocol to offer you, what is your ovarian reserve, also to assess if your uterus is normal if there is any malformation, where the ovaries are located or if it’s going to be easy to access the ovaries to perform the egg collection. So we get a lot of very important information from the ultrasound image so absolutely yes.
Dexamethasone is a corticosteroid and this is also something used for patients who have recurrent implantation failure or miscarriages to try to balance the immune system and try to aid implantation.
When we’re speaking about IVF with your own eggs, age is probably the most important factor determining whether you will have a successful outcome. So, yes, it plays a role and it’s a very important factor to take into consideration.
Then the second thing, we understand that it’s confusing to know which are the best and if they are necessary or not. What I would suggest is that you take those questions that I explained at the very end of the presentation and ask your doctor which of these add-ons are going to make a difference to my likelihood of live birth. There are some patients that might benefit from some specific things, there are patients where there’s not going to be any difference at all if they use any add-on and also it’s important to individualize and tailor each treatment to the needs of each couple or patient.
The important thing is that the ERA test is done in the exact same circumstances before your actual embryo transfer takes place. So if you are going to have embryo transfer with a natural cycle, then you have to do the ERA test on a natural cycle. If your embryo transfer is going to be done in stimulated cycle, you have to do it on the stimulated cycle. Having said that, usually, it’s a little bit easier to have more control when we use simulated one but both options are available and it has to be discussed with your consultant which of those is the one that will be better in your specific case.
It’s a little bit the same as the other techniques that I explained for choosing better sperm. We don’t have any specific data saying that this would increase the live birth rate.