Why do I experience miscarriages after IVF?

Dr German Fernández
Medical Director , UR Vistahermosa

Miscarriages and RPL

From this video you will find out:
  • What are the main causes of miscarriages?
  • What evaluation tests must be done to find the cause in women and men?
  • How can the IVF results be improved?
  • What can be done for recurrent miscarriages?

What causes miscarriages after IVF?

In this webinar session, Dr German Fernández, Medical Director, Gynaecologist specialising in Reproductive Endocrinology and Infertility at UR Vistahermosa Managua has discussed miscarriages causes, available diagnosis and treatment options.

Dr Fernández started by explaining that miscarriages are very common and around 10 to 20% of spontaneous pregnancies end in miscarriage. Most of them, around 80%, happen before 12 weeks and from 60% of a positive pregnancy test, 34% end in happy ending pregnancy. It is important to understand that even if you do an IVF treatment or not, there is a certain percentage probability of having a miscarriage. Many times people are wondering about how you can have a miscarriage if you are doing an IVF process, but even if you don’t use an IVF process, you can have a miscarriage as well as you can have, for example, preeclampsia, pre-term delivery, diabetes or whatever disease you may have in a normal pregnancy.

Miscarriages – causes

One of the main questions the patients ask: Is it me? Am I doing something wrong? And what is significant to remember is that egg quality is different from egg quantity. Sometimes even though you have a good AM level and Antral Follicle Count doesn’t mean you have a very good quality of those eggs. Another reason for miscarriages could be an underlying disease, such as untreated subclinical hypothyroidism, insulin resistance, or any previous diseases.
It is also known that if the progesterone levels are low in the luteal phase, the risk of miscarriage increases. Therefore, many times in an IVF process, we prescribe vaginal progesterone for patients to increase their levels.

It is also important to mention the male part. Sometimes we have a sperm analysis that says there is good concentration, very good motility and morphology, but we don’t know if this semen is indeed of very good quality. That’s the reason we do some other tests, for example, DNA fragmentation, and FISH, we also need to check if the partner has diabetes, ejaculation issues, if he smokes and if there were any previous miscarriages. Studying men is as significant as studying women.

Sometimes the cause can be found in both partners. The lab also has some responsibility, for example, creating an optimal environment for fertilization, and having an adequate preparation of patients, therefore, we always need to calculate the right dosage for each patient to obtain very good eggs. If we know, for example, that the progesterone levels are high, we freeze the embryos and do a transfer in a later cycle. Another crucial part is personalized treatment because not all patients need the same thing.

Improving IVF results

There are certain things that all patients undergoing IVF should remember and which can be crucial in their journey. These are:

  • preparation
  • following the doctor’s instructions
  • if there are some questions or doubts, always ask and don’t hesitate
  • ask about your own pregnancy chances and live birth rate

I would also recommend all patients to take notes about their cycle because if you need to change your doctor, you will be able to provide thorough information. I would always ask how long you’ve been trying for, how was your egg retrieval, have you got mature eggs, did they fertilize, what grades your embryos were or if you had an easy or difficult transfer, etc. Thanks to that, I could probably provide a bit different prognosis. Those questions are very important to answer, and you have to take notes.

Basic tools for surviving an IVF cycle

  • keep connected with your friends and family, and ask someone you trust to give you accurate information
  • get as much information as you can get from your doctor, no Internet or forums
    • keep in mind, that there is no ‘formula’ that works for everyone
    • there are other issues than just information from the clinic such as empathy, ability to give suitable information, communication skills, clinical practice
    • information on forums can be influenced by the character, personality, and sensitivity of the author
  • trusting your doctor is the most important thing during the process

Another thing you should take into account is to find the answer if it’s better to transfer 1 embryo or more embryos at once. That always depends on the embryo classification, but also regulations in your country. Another thing is to consider the risk of twins or triplets if more embryos are transferred. At some point, you also might need to decide whether to change one of the gametes and also how far would you like to go through your process because if there’s a problem with let’s say your eggs or your partner’s sperm, you might need to change to egg donor or sperm donor to achieve a healthy baby.

- Questions and Answers

What is the ideal medication protocol to sustain a pregnancy with donor eggs? How much progesterone, estrogen, and other drugs do you prescribe and for how long? I read on the website that some clinics recommend taking progesterone until 30 weeks. What do you think about taking prednisone?

It depends on the background of the patients. If you already had recurrent pregnancy losses or miscarriages, I would use, for example, I would use a very low dose of prednisolone until the 12th week of pregnancy. In donor eggs, we use estrogen, it usually depends on how much estrogen we’re going to use, we usually use up to 10 milligrams per day and progesterone around 800 per day, but some protocols use a 10000, it depends on the administration and also if you use this progesterone vaginally or if you use it in a shot. You may use estrogen from 6 to 10 milligrams without any problems, and progesterone you can use from 800 to 1000. In case a patient has recurrent miscarriages or previous implantation failures, we use prednisolone, and Viagra (sildenafil), we also use inositol, but it all depends on the patient. Regarding taking progesterone until 30 weeks, it depends because if we have a patient who already knows that has uterine incompetence, you may use progesterone longer, but normally, in an IVF process, we use it until 12th weeks.

What are the reasons for donor egg miscarriages?

That’s a very important question because we have to understand, as I said at the beginning of the presentation, that miscarriages occur even though you do a natural cycle. People usually get confused about that. They think that if they have a 25 years old egg donor and husband’s or partner sperm, they will probably have some guarantee that nothing is going to happen, or they will have a certain guarantee that the fertility rate is going to be very high because they’re using an egg donor. However, it’s not like this because we have to understand that the semen of the husband may have DNA damage, and that is why that can cause or increase the miscarriages chances as well.

Some experts say that the egg is the most important part of IVF, about 70%, and the rest, 15% sperm and 15% uterus factors. In conclusion, IVF with donor eggs must be very successful, unfortunately, I had 2miscarriages with donor eggs in 4 attempts. What is your opinion?

Unfortunately, we have to say that some patients have the same issue. At the moment, I also have a patient who has already gone through IVF with donor eggs, and she hasn’t been successful yet. What we do is change the donor, for example, that’s one option, another option is using an endometrial rejuvenation, you can use intra lipids to increase the chances of getting pregnant. But first, I would check if those eggs are from the same donor or if they are different, if not, I would say there might be something going on with the semen. If you already have 2 egg donations, perhaps you will need to pursue embryo donation at some point, and as I said at the end of my presentation, I believe everyone can get pregnant, the thing is, how far are you willing to go.

What do you think about taking preventive low-dose aspirin before and after the embryo transfer?

We do it all the time. Here in Nicaragua, you have to pay for every test, for example, if you want to get a genetic test, you have to pay for it, and if you want to go through an IVF, you need to pay. We don’t have a chance to do a thrombophilia test for everyone because if we do that, we’re making the process even more expensive. We use low doses of aspirin for every single patient, after COVID we have increased the dosage to 380 milligrams per day, but it depends on the country.

After FET, would you recommend bed rest for the 10-day wait for someone with a history of miscarriages and implantation failures?

I would have some doubts about it because the implementation rate doesn’t depend on the bed rest, it depends on how the endometrium is prepared to receive an embryo. We don’t recommend bed rest much, it is not a regular recommendation. We just recommend 2 days of bed rest, but not like very restricted, you can do the dishes or prepare some food and things like that. We don’t want the patient to just lie down for 10 days.

What semen processing do you use? Gradient, swim-up prior test to SA/IUI or IVF?

Gradient, but it depends on the lab. Most of the time here, and we’re an international group, we always use gradient, but in some cases, we use swim-up if we have a very low-quality semen sample.

I had a miscarriage last week at about 8.5 weeks and had surgical management on Friday. I was pregnant for my second round of IVF with a sperm donor and my own eggs. I have no known fertility issues but had to do IVF as I am single. My embryos were created when I was 41, I’ve just turned 42. I have 2 frozen embryos, but I want to do another IVF cycle asap because of my age. My AMH is 2.4, how long should I wait after the procedure till I can try again? Is there anything I can do to improve my chances?

What we are doing now here is the endometrial rejuvenation, we use PRP in the endometrium and also intralipids. The other thing is you should try it for like 3 months, that’s usually the recommendation.
Can Endo-PRP (endometrium rejuvenation) treatment improve your endometrial thickness?
Do you trust your clinic? Building, training and tuning your BS detector
Fertility preservation & egg freezing: understanding your options
Advanced maternal age & egg donation in Spain: exploring your options
Diagnostic evaluation & management of male infertility
Personal boundaries in your fertility journey: what are they,  how to put them in place, and why you might need them
Dr German Fernández

Dr German Fernández

Dr German Fernández, Medical Director at UR Vistahermosa Managua. He is a Gynaecologist specialized in Reproductive Endocrinology and Infertility, graduated in Spain. He is an expert fertility doctor in one of the Latin American clinics of the UR international group. His work and commitment to patients have awarded him as an international professor and speaker in Chile, El Salvador, Guatemala and Panama. Former Director of the Clinical Research Department of the Bologna Hospital and member of the American Society for Reproductive Medicine. His most recent achievement is having recently been accepted to study for a Masters at the Imperial College, London (UK).
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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