Diana Obidniak, MD
Fertility Specialist, Head of ART of Birth Clinic, ART of Birth Clinic
Category:
Embryo Implantation, Embryo Transfer, Failed IVF Cycles, Miscarriages and RPL, Success Rates
‘I faced so many patients with ineffective IVF attempts that I dedicated all my time, energy and inspiration to create approved practical guidelines. 9 years later, my team has 4 international awards from the American Society of Reproductive Medicine, 2 patents for invention and viable protocol’.
‘Chronic endometritis is a condition involving the breakdown of the peaceful coexistence between microorganisms and the host immune system in the endometrium, resulting in a special type of chronic inflammation in the endometrium, characterized by non-apparent clinical signs.’When the patient is suffering from chronic endometritis, inflammation in the endometrium doesn’t cause any pain or elevated temperature. General inflammation in the body is not absorbed, but we see that as a chronic process. Usually, there are some morphological changes, for example, micro polyps or synechia. They will notice that their menstrual bleeding quality changes, for example, the bleeding becomes more brownish, the bleeding lasts longer than usually those 3-4 days and the last days are not that intensive, but it is more brownish. In the general population, chronic endometritis can be found in approximately 10%, but if we look at more difficult cases, for example, with several failed IVF attempts, we will see that chronic endometritis is present in 30%. If we look at recurrent implantation failure with good quality transferred embryos, chronic endometritis will be identified in 60% of cases. In a group with recurrent pregnancy loss, we observe chronic endometritis in most patients in 66%. Therefore, the treatment plan should include a diagnosis of chronic endometritis. If we verify it, we should treat chronic endometritis and prepare endometrium properly.
Nowadays, we understand that the uterus is not sterile at all, and we have a lot of microorganisms, we have a normal microbiome and abnormal ones inside the uterus. The uterine microbiota plays a great role because your uterus is like your apartment for your pregnancy. Embryos prefer good conditions from the first day, that’s why if they don’t find the good condition inside, they will never implant. We divide all the microorganisms into residents, tourists and invaders. Invaders are the riskiest group, we have a lot of trials concerning microbiome in recurrent pregnancy loss and repeated implantation failure. There are a lot of papers concerning uterine microbiota which are rather difficult to understand. There are a lot of microorganisms, but normally we have so-called lactobacillus dominant. If the microbiome consists of lactobacillus dominant, there are good conditions for implantation. Sometimes, specifically in inflammation, we have another microorganism that prevails, and the implantation doesn’t occur.
On the other hand, we have functional alterations, so-called compromised window implantation. In natural life, the embryo development and the receptivity of endometrium are synchronized, that’s why if the processes of embryo development and reaching maximal endometrial receptivity are de-synchronized, we will never obtain a pregnancy. Therefore, we now have 2 tests which are called ERA tests and the BeReady test. Both of them use the same technology, they give us their personalized perfect time for embryo transfer, and it results in a great outcome. Both of those tests have very similar results, and we use and implement them in our practice.
On the slide, there are three groups where that compare frozen embryo transfer with fresh embryo transfer and so-called personalized embryo transfer. The number of embryo transfers was 1.7, so sometimes they transferred two embryos, sometimes one embryo, but they tried to transfer just one embryo. CPR means clinical pregnancy rate per embryo transfer, we see that when the team of investigators implemented frozen embryo transfer, the result was 61%, fresh embryo transfer 60%, but when they use personalized embryo transfer, the CPR ( clinical pregnancy rate) was 85%, which is a great result. Dr Obidinak said that her team was the first team who started this personalized embryo transfer in Russia because we work with the most difficult cases, and so far, we had an impressive outcome.
The first patient had eight embryo transfers with PGT-A done at different clinics, but the couple never had a positive pregnancy test, and we just performed one test, and then we performed embryo transfer which resulted in pregnancy, and the pregnancy went very well with no complications, no risks and great delivery with a healthy boy. Then we had 10 or 11 cases ending in positive results, that’s why it’s our routine practice nowadays, and we use personalized embryo transfer very often.
On the analysis report of the BeReady test, we see this scale of receptivity, and the normal rate is 100 points. If we have more than 100 points, as in the first picture, we can see that this is a post-receptive endometrium, so we should perform the embryo transfer a bit earlier. If we have less than 100 points, we consider that endometrium is pre-receptive, so we should perform the embryo transfer later than it was.
A routine embryo transfer can be performed in a fresh cycle on day-5 after egg retrieval or as a frozen embryo transfer. Nowadays, in most cases, we perform frozen embryo transfers on a specific date. Usually, we do it 5 days after we start to give progesterone, so we do the embryo transfer on the day- or day-6 of progesterone administration. When they investigated the window of implantation, we got the information that only 65% of women have standardized time frames for the window of implantation. The implantation window is connected to the process of embryo development and reaching maximum receptivity. In most cases, the implantation window is delayed or can occur earlier than these five days. That’s why when we transfer the embryo inside the uterus, and the endometrium is not ready or is over matured. This connection between embryo and uterus just doesn’t occur properly, and we see no result. The idea is to make the trial preparation cycle, and on the day when we wanted to do embryo transfer, we do a biopsy of your endometrium, we do not perform the embryo transfer on that cycle, but we investigate this sample of the endometrium to assess and detect the perfect time for embryo transfer precisely. In the following cycle, we perform embryo transfer not according to a standardized protocol and not on day-5 but the perfect time for you, and it gives a great result. It’s one of the instruments which resulted in such a high success rate in clinics.
It doesn’t do any harm, but there are no great benefits of IVIG. It gives a very small room for implementation, it can be beneficial in APS syndrome and some very severe autoimmune diseases. However, it doesn’t provide any benefits in routine practice for a recurrent implantation failure. The thing is that the injection of IVIG should be performed only inside the clinic because one patient from one country told me that she’s ready to do it at home, please don’t do it by yourself, only according to the administration of your physician.
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Contact details: The European Fertility Society C.I.C., 2 Lambseth Street, Eye, England, IP23 7AGAnalytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc.
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