Well, it is quite a difficult condition because you had PGS. I would like to know how did you respond to the IVF, if your ovarian reserve was normal or not, how many embryos were tested, how many of these embryos were and then based on that because in most implantation failures are due to abnormalities in the embryos. The hydrosalpinx sometimes plays a role, it is a small amount of fluid that is inside of the tubes.
One of the things that sometimes we recommend in this case is adding aspirin and heparin as I have explained before, starting with the aspirin 4 weeks before the embryo transfer. Probably you also had some frozen embryo transfers. One thing that could be interesting in your case is that because of the hydrosalpinx, sometimes, there is a problem that has to do with endometrium, it could be either chronic asymptomatic endometritis which is an infection that is not going to cause you any pain, any issues, any discharge, any fever, but is causing excessive inflammation in the uterus or sometimes there could be an abnormal microbiome which means that inside of the endometrium there should be a different percentage of bacteria as it happens in the vagina there should be more than 90% of lactobacilli.
The diagnosis of the endometritis is very subjective when it is done in hysteroscopy. You can see that it is a bit deeper vascularized, there is a big redness because of the vascularization but the only way of discarding that there is a bacteria there, that can cause any problem, is doing an endometrial biopsy. We have to test one is called Emma the other one is called ALICE and the ALICE checks if there is any small amount of the DNA of bacterias which is very accurate diagnosing endometritis, and the EMMA checks that the percentage of normal bacterias is correct one. If they were normal there is no need to repeat them, we only need to repeat EMMA and ALICE when they are abnormal. ALICE is usually treated by giving you an antibiotic but if you had a positive ALICE, we recommend doing another biopsy to confirm that the bacteria is no longer there. Sometimes bacteria may be resistant to the antibiotics, so it’s worth doing another biopsy to confirm that the bacteria is gone.
If the EMMA is abnormal we will recommend vaginal probiotics to restore the normal population of bacteria, and it is not usually needed to redo a biopsy because in this case, the second biopsies have confirmed that in more than 95% of cases the flora is normal. The only thing that I would suggest in your case then, it may surprise you, it would be checking the sperm. The reason is that, in the DNA of the sperm, there is some study that has suggested that it is very active at the surface of the placenta, so the sperm may play a relevant role in the implantation. I’ve got cases in which we have been able to demonstrate that there was a genetic problem in the sperm that we have done PGS to choose the genetically normal embryos and the patients have not gotten pregnant. I had a very spectacular case. We demonstrated that there was a genetic problem in the sperm, the couple decided to try with the man sperm and went through PGS, they did 8 egg donation cycles, that means 8 donors, we transferred 25 euploid blastocysts, and we only had 2 biochemical miscarriages. At that stage, we were so desperate that surrogacy was suggested. Because of the abnormal genetic problem of the sperm, we recommended double donations, so changing the egg and the sperm because it was already an egg donation and see what happens. It was much easier to do a double donation than to consider surrogacy, so they eventually decided to do a double donation, we had 5 or 6 blastocysts, we transferred 2 and she got pregnant with twins, and she had 2 babies. In the end, this is a cycle that in my opinion, confirms that sometimes when you check the sperm and you have an abnormal genetic or abnormal problem it’s like an iceberg, you see what is outside the water but you cannot see everything below. In this case, we did exactly what was supposed to do, there was a genetic problem, we did a lot of PGS, no results, we changed the sperm, and she got pregnant on the first transfer with twins, and now they are 3 years old.
So that’s why sometimes it’s worth to do, some kind of genetic testing on the sperm despite transferring genetically normal embryos because if there is anything abnormal, probably you would have to consider a change in the sperm.
With regards to the FISH, it is a test that only checks 3 chromosomes, it has a good sensitivity that means that when we have an abnormal FISH, we know that in 93% the sperm is normal or not, but there is a 7% of cases where FISH is normal, but it still could be a genetic problem in the semen. In such cases, the meiotic study is recommended as it checks the different phases of the semen, how the sperm divides so it basically let us see how the chromosomes behave and also if there is some kind of problem in the middle and not like that is not evident in the final product in the sperm, it can also be detected.