In this webinar, Dr Laura García de Miguel, Medical Director at Clinica Tambre, Madrid, Spain, has discussed recurrent miscarriages and presented one of her past cases where a couple in their mid-30s struggled to have an ongoing pregnancy after conceiving naturally 3 times.
Dr García started the presentation by covering the definition of recurrent miscarriages and took us step by step through all aspects of one of the clinical cases, starting with a general description and situation, diagnostics and procedures until the live birth.
According to ESHRE, recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies, excluding ectopic pregnancy and molar pregnancy. It is considered when it happens before 20 weeks of gestation.
A couple in their mid-30s, the female was 34 years old, and the male was 37 years old. They had no previous unsuccessful IVF attempts, but after conceiving naturally 3 times, all ended in miscarriage. The couple had no family history, no diseases, no medications and normal BMI. We studied females’ ovarian reserve, karyotype testing, we also wanted to exclude uterine malformations, endometritis, coagulation disorders and immunological disorders. We also checked general spermiogram parameters and wanted to see if it’s necessary to do a FISH test, a genetic test, and DNA fragmentation to see if there are any fragmentation in the DNA and also karyotype. Partner’s results were normal with good volume, good concentration, good mobility and no problems with morphology. Karyotype was 46 XY.
We started studying a female’s ovarian reserve, and it was pretty normal, she had 1.8 ng/ml of AMH, and she had 10 AFC. The karyotype revealed that she had a Robertsonian translocation (ROB) between chromosomes 13 and 15. In this particular couple, that was the issue. Nevertheless, we also did an ultrasound, and there were no uterine malformations or fibroids and no hydrosalpinx. We performed thorough coagulation testing, including thrombophilia, antiphospholipid syndrome, and everything was negative. We also excluded celiac disease, NK cells. She had a good vitamin D level, no problem with glucose-insulin metabolism or thyroid.
It is extremely important to do a karyotype for both partners, even if there are no miscarriages, we always recommend doing a karyotype before going ahead with IVF. A karyotype is a blood test that confirms the number of chromosomes. All humans have 23 pairs of chromosomes, and we have structures that confirm if we are chromosomally normal or not. In that female patient, there was a structural problem, between chromosomes 13 and 15, instead of having 46 chromosomes, she only had 45 because an arm of chromosome 15 fused with chromosome 13. People who have Robertsonian translocation (ROB) have no phenotypical problems, so everything is healthy for them, however, they can have problems with reproduction. They can have more risk of miscarriage and less possibility of pregnancy. Translocations occur when the chromosome is joined with another chromosome. Robertsonian translocation (ROB) usually involves chromosomes 13, 14, 15, 21 and 22 and generally, the possibility to find euploid embryos in people who have this translocation is less likely. It’s a 33% probability of finding a euploid embryo, but when the translocation is in the female, the possibility is even less, it is 18%.
Therefore, we decided to do IVF with ICSI and PGT-SR to exclude problems in chromosomes in embryos having structural abnormalities. ICSI (Intracytoplasmic Sperm Injection) is a procedure where we inject sperm directly into each egg, we are always doing ICSI when we need to do genetic screening or genetic or PGT-SR, it is possible to do it with traditional IVF, but it is recommended to do it with ICSI procedure. We use a micropipette and a holding needle in our laboratory. We always use a microinjector, which is necessary for biologists. We always prepare eggs on the day of the egg retrieval, and we prepare sperm.
When a woman has a period, we always confirm with our patient in the initial ultrasound if everything is okay to start with injections and do the ovarian stimulation. Five to six days later, we do ultrasound number 1, then every 48 hours, we do ultrasound 2 and ultrasound 3 to check the development of the follicles. Then we do the egg retrieval, this is called day 0, and it’s the same day when we ask the male for sperm. In a traditional IVF, we leave all these embryos from day 0 to day 5, and we do the embryo transfer, and 11 days later, we do the pregnancy test. However, when we need to do PGT, we don’t do the embryo transfer in this fresh cycle because we need to do the biopsy of the embryos, and embryos remain frozen. Once we have the results, we organize a call with the couple to explain the genetic results so that we can prepare endometrium before embryo transfer.
That female patient had a low possibility to find at least 1 embryo within only 1 cycle, so we recommended doing the double stimulation. In the same month, we simulate twice. In the first round, we do the egg retrieval, and 4 or 5 days later, we start another stimulation. Then 2 weeks later, we start another stimulation and second egg retrieval. Why did we recommend that to this couple? That’s because she was only having an 18% possibility of normal embryos, so that was the reason we recommended doing the double stimulation and increasing the possibility of creating embryos.
We did an IVF cycle with ovarian stimulation, and we did a biopsy of the blastocyst. Every single embryo we study, and we are doing day-5 or day-6 biopsy before the transfer, increases the chances of having a healthy baby because it is offering the possibility to reduce the risk of miscarriage and increase the probability of pregnancy per transfer. It also reduces the duration of treatment and the number of cycles needed. PGT, in general, means Preimplantation Genetic Testing of embryos. PGT-A refers to Preimplantation Genetic Testing for aneuploidy, so it’s for people having problems in chromosomes such as maternal age or previous IVF failures. We also have PGT-SR, which stands for Preimplantation Genetic Testing for structural chromosomal rearrangements, and that was the test that was performed on the embryos of this couple. It detects alterations in the structures, not only the number of chromosomes. It also allows us to see if there are translocations. PGT-M (Preimplantation Genetic Testing for Monogenic Disorders) is for couples having risk to transmit any disease to their babies.
In their first round, the couple got 3 blastocysts, and in the second round, 5 blastocysts, they got 8 blastocysts in total. All the blastocysts were biopsied and sent to the genetics laboratory. PGT-SR revealed that only 1 embryo was euploid, so without translocation. A euploid embryo contains 23 pairs of chromosomes, whereas an aneuploid embryo has a gain or loss of genetic material, problems with chromosomes that could lead to miscarriage or babies born with chromosomes disorders such as Down syndrome.
We did a natural cycle for endometrium preparation, we monitored ovulation and when the endometrium was more than 7 millimetres, and the follicle in the ovary was more than 16 millimetres, we triggered the ovulation and did the embryo transfer 7 days later to reproduce the window of implantation as she had in the natural cycle. Then we did support of the luteal phase with progesterone of 400 mg every 12 hours, and we did the embryo transfer with abdominal scan monitoring. Eleven days later, we did the pregnancy test, fortunately, we had an ongoing pregnancy with no complications.
It is very important to study all possible causes when we deal with repeated miscarriages, and we need to remember it could be more than one problem. Even if the karyotype is normal, PGS/PGT is recommended. When we deal with miscarriages, it is recommended to only focus on normal embryos. When we find translocations, it is necessary to talk with the couple and explain the possible percentage of normal embryos that we could find.
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.
According to our medical evidence reports, we need to start studying this kind of problem (thrombophilia) when there is more than one miscarriage. We need to consider other factors, such as concerns in your family, coagulation disorders. In your case, in particular, it would be quite understandable to do a thrombophilia study and see if you need to use heparin or baby aspirin, but of course, the most important is always the age of the embryos.
At this point, as you were 38 years, it’s not that likely for the miscarriage to occur because of thrombophilia, it’s more likely to be because of maternal age. As long as you have 2 embryos frozen, and probably you don’t have more possibility to go ahead with other embryos, then I would say to exclude thrombophilia issues first.
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 have had different failures with good blastocysts, I would study whatever is possible before going ahead with other embryo transfers. I would suggest ERA, EMMA, ALICE to exclude problems with endometrium. Also, study a 3D scan, MRI, or hysteroscopy to exclude issues with your uterus in terms of the cavity and also immunological and coagulation issues. Remember, if your embryos were not PGT-A tested, it’s something you always need to take into consideration for your next embryo transfer.
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.
Next-generation sequence testing and FISH are different techniques for chromosomes studies. NGS studies the 23 chromosomes, and FISH depends on the number of groups, normally 5 or 8. We cannot say 100% with 4 or 5 cells that we will study from the blastocyst that the embryo it’s 100% euploid.
When we perform PGT-A carried out on day-5 or day-6, we study the external part called trophectoderm, the karyotype of that embryo in particular, and we have euploid embryos, on the other side, we have aneuploid embryos and then we have mosaics. This is the result of those 5 cells, and we cannot say 100% sure if this is euploid or not. The accuracy of this test is extremely high, so I would say you need to rely on that test.
Yes, we’re offering and doing it very often, and it normally takes two weeks for the results.