Adenomyosis disorder in the uterus can lead to miscarriages. When we’re talking about adenomyosis, we need to inform the patient that there are special protocols to prepare the uterus, and it’s with 3 months of agonists. We cannot perform ovarian stimulation and embryo transfer in the same cycle, we need to first work with stimulation, create embryos, I would recommend doing PGS and then work with endometrium and only transfer after 3 months of Decapeptyl agonist.
If other factors are involved in these problems with repeated miscarriages, we also need to work in parallel. We don’t want to use Prednisone as an empiric treatment, only if it’s necessary. I would strongly recommend performing PGS and working on endometrium preparation for 3 months with agonists. Also, exclude other possible problems apart from adenomyosis.
You need to be optimistic, implantation occurred, so you’re closer to your full-term pregnancy. I’m happy to inform you that this is not a rare case, it’s not that unlikely, so you need to continue working with your GP, and you need to transfer another embryo.
If you have had curettage, you need to wait 3 months, but if it was a natural miscarriage, then 1 month is okay. With one miscarriage, it’s not necessary to study the possible causes, of course, you can do it, but it’s not necessary, so I would suggest talking with your GP and looking at the number of embryos that you still have, and if your GP will suggest there could be problems, you should decide together whether it’s better to do any tests before going ahead or if you can just go ahead.
The most developed, so the most expanded, and the best quality embryo is the most viable. However, it’s not only morphology, genetics is crucial as well. Morphology is very important, but if you’re having repeated miscarriages, I would say PGS should be done before transferring, but of course, it’s extremely important to check if PGS is offering you an advantage or any disadvantages.
For patients with low ovarian reserve, I don’t recommend freezing embryos, I strongly recommend trying to create embryos, and, if possible, transfer them. If I had a young patient, and she eventually would like to have more than one child, then yes, I would recommend doing double stimulation and trying to freeze at least 1 embryo for the future because what happens if in that patient, in particular, achieved pregnancy, and then she comes back at 39 or 40 years and if at 37 she has a low ovarian reserve, at 39 or 40 it will be even more difficult. This is always something that we can decide together if it is convenient or not.
Immunology is a big part of miscarriages problems and also with implantation failures. We start with the killer cells testing to be sure if you have an abnormal KIR, which will be KIR-AA which means that you have more risk of miscarriage, and we need to see if we need immunological treatment for that. We also check natural killer cells to see if you have more risk to kind of attacking your embryo with the natural killer cells, and again we need to use Prednisone. We also need to check for celiac disease, thyroid issues, metabolism of glucose and insulin, and any other autoimmune issues that you could have. We need to see if you need treatment to suppress that immune system.
It depends on whether we do PGS or not because we can offer double stimulation without PGS as well. The cost for a traditional IVF is around 8 000 EUR, whereas double stimulation with PGS is around 12 000 EUR, but I’m not 100% sure, it’s always much better to contact our coordinators (Clinica Tambre) to get the exact prices.
Repeated chemical miscarriages are also considered miscarriages. We need to individualize this and see if you know again the age of the egg was when you were like less than 38 or if you were 38 or more and if it was after natural pregnancies or after PGT-A tested embryos but again if they are considered miscarriages.
It’s not that freezing makes the embryos more resistant because we are performing more invasive procedures. By contrast, the freeze all studies suggest that normally endometrium is more receptive in a frozen embryo transfer compared to an IVF natural cycle. The benefit is not because the embryo is having a more energetic possibility or more resistance, it is because of the endometrium. That’s the reason in low ovarian reserve, it’s always our objective to create at least one embryo, and it’s a challenge because it’s not that easy. We need to individualize to see if it is convenient or not to freeze this embryo and be at risk of not thawing that embryo.
My last patient also had repeated miscarriages, we did PGS, and we achieved 3 euploid embryos with dual stimulation, they were frozen. On the day of the embryo transfer, the first embryo was not able to survive. We thaw the second embryo, which means that we create one embryo, but we still were not able to transfer it because it didn’t survive.
In that case, it is extremely important to exclude genetic problems because this is the main problem for all my patients who are around 39 years old. You should start with checking your karyotype, and if your karyotype is normal, even though in your country PGS it’s not possible, I would think about going abroad and trying to exclude embryos. I had a patient who was 38 years old, she had 5 blastocysts within only one IVF cycle, but those 5 blastocysts were abnormal, so imagine if that is your case.
If you had a normal pregnancy, but right now you’re having repeated miscarriages or no implantation, the main issue is the quality of the eggs. I would recommend doing PGS to be sure that your embryo is normal or not if you want to continue with IVF. You can think about doing more immunological testing, to exclude any issues in your endometrium. However, in medicine, in more than 50% of repeated miscarriages, it’s because of genetics. When we are having a patient the age of more than 38, it’s more than this.
If you had a child already, it is very unlikely to have HLA incompatibility. I cannot say 0%o per cent, but it’s extremely unlikely that HLA is the problem. I would say you should study your ovarian reserve, take into consideration the quality of sperm and see if you need to do PGT-A testing or not, and if PGT-A reveals that you don’t have a normal embryo, then you could know the reason why.
If you only have, for instance, 1 normal embryo, I would suggest studying whatever is possible to maximize the possibility of implantation.