About 18 months ago I saw an Asian Indian couple who presented with a very interesting history. The female partner (whom I will refer to as DB) had regular menstrual cycles and normal ovarian reserve, was ovulating regularly and had a fertile male partner. DB, who was 34 years of age, had been diagnosed with pelvic Tuberculosis (very common in their homeland, India).

A diagnostic laparoscopy/ hysteroscopy and D&C was done and revealed bilateral tuberculous tubal occlusion with hydrosalpinges (fluid collection in both tubes) and ruled out uterine infection (tuberculous endometritis). Both her Fallopian tubes had been removed at laparoscopy. There was a positive family history for autoimmune hypothyroidism (Hashimoto’s disease).  The couple had been through three prior attempts at IVF. The first IVF procedure which was done in India had resulted in a pregnancy that advanced to 7 weeks, then spontaneously miscarried. The products of conception were submitted for chromosome analysis and were found to be normal (46XY). The second and third IVF procedures both failed to result in pregnancy, in spite of transferring two good quality, well-expanded blastocysts on each occasion.

Evaluation at SIRM: This history was highly suggestive of an implantation dysfunction. The first thing I did was to re-biopsy and re-culture her endometrium for tuberculous endometritis. This again was negative. I then checked for endometrial thickness by ultrasound at the time of presumed ovulation and found this to be normal. I did a sonohysterogram (saline sonogram) which confirmed that the contour of her uterine cavity was regular. I had her blood tested for thyroid function, which, apart from a modestly elevated Thyroid Stimulating Hormone (TSH) level, was entirely within normal limits.

Finally, I sent her and her husband’s blood to a Reproductive Immunology Reference Laboratory where she tested positive for antithyroglobulin antibodies as well as for natural killer cell activation (NKa). Concomitantly performed, side-by-side analysis of her and her husband’s blood showed no evidence of DQ alpha/HLA matching.

Conclusion: The diagnosis made was autoimmune implantation dysfunction.

Treatment: A cycle of IVF was initiated, using an agonist/antagonist down-regulation protocol of stimulation.  A regimen of intravenous intralipid and oral dexamethasone therapy was commenced about 1 week prior to egg retrieval. Eleven eggs were harvested. Eight were mature and were fertilized using intracytoplasmic sperm injection (ICSI). Two good quality expanded blastocysts were transferred and two more were frozen (vitrified) and stored. The patient conceived, at which point she received  a second infusion of intralipid and continued with oral dexamethasone therapy to the ninth week, at which point it was tailed off and then stopped over a 10 day time period.  DB went on to give birth to a healthy baby boy at full term.

Commentary: Pelvic tuberculosis, while a common cause of infertility in Asia, is very uncommon in the United States. In fact, few Reproductive Endocrinologists ever get to see such cases here. The condition does however cause refractory infertility.  Involvement of the fallopian tubes is the most common presentation. Ovarian involvement is second on the list and in 10% of cases it causes inflammation of the uterine lining (Tuberculous endometritis) which, in the IVF era, is the most common form of pelvic tuberculosis to cause irreversible infertility due to refractory implantation dysfunction. That is the reason why I retested DB for Uterine involvement.

However, the fact that DB actually had conceived a chromosomally normal male conceptus immediately suggested implantation dysfunction. The family history of Hashimoto’s disease  and her slightly elevated TSH led me to suspect that this might be associated with NKa, and so it was.  The treatment I implemented with intralipid and steroids to down-regulate the NKa was successful in regulating this, and she subsequently conceived and went on to achieve a live birth.

Women who present with reproductive dysfunction (infertility, unexplained IVF failure, recurrent pregnancy loss, and who have antithyroid antibodies (regardless of whether they have symptomatic hypothyroidism or not) will in about 50% of cases have an associated activation of uterine NK cells (NKa) which can interfere with implantation and present either as previously “unexplained infertility” or as an early pregnancy loss (a chemical pregnancy or a miscarriage). It is thus imperative that women who have an elevated TSH, as well as those with a personal or family history of hypothyroidism (especially when it occurred on their mother’s side of the family) be tested for antithyroid (antimicrosomal and antithyroglobulin) antibodies and for NKa (using the K-562 target cell test and/or by evaluation of endometrial TH-1 cytokines).

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This is the second in a series of posts taken from questions that have been submitted to me via email, website, or discussion boards.  This question is from a patient who had a healthy baby from her first pregnancy, but then went through a period of 6 consecutive  miscarriages/chemical pregnancies.  I have included her original post, followed by my responses along with the details of the patient’s eventual treatment.

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(Mid 2011)

Dear Dr Sher,

Thank you for this discussion board. It is a great help to those like me, who have feel like we are not getting the right answers, are floundering and quite frankly feel desperate. Here is my (sad) story…please help!

I am 37 years old and have had 7 pregnancies. The first one occurred 8 years ago and we have a beautiful little girl who is the light of our lives. The next two pregnancies also came without difficulty but both miscarried around the 8th to 10^th week. So we went to see an RE who suggested that I was not ovulating properly…something to do with my hormone balance. He suggested IUI so we went through 5 of those using Clomid. I got pregnant once and this time miscarried at 6-7 weeks (a heartbeat was detected by ultrasound in each of these two cases). The next suggestion was IVF, which I have since gone through six times, with three chemical pregnancies.

My husband has normal sperm. He and I have had genetic blood tests which turned out to be normal. I have had a dye X-ray test, as well as a hysteroscopy and was informed that I have a normal uterus. I am told that even my uterine lining develops normally; measuring 12mm at the time I received the hCG trigger.

Frankly I am not getting any answers. None of this makes any sense to us. Why did I have a baby with no difficulty eight years ago and then have everything go downhill? Please give me advice….Help!!

Darla (Patient’s name has been changed)

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My response in 2011:

Dear Darla,

Thank you for reaching out to me. I understand and empathize with your plight.

I have little doubt that your problem relates to embryo implantation dysfunction….most likely immunologic in origin.  You ask why you would have had no problem with your first pregnancy, yet have so much trouble in ensuing attempts. Well, the likeliest explanation would lie in your having an immunologic implantation dysfunction (IID), which, based on history alone, is most likely to be alloimmune (rather than autoimmune)  in origin. This type of IID occurs where both partners have DQ alpha or HLA genes in common. When this happens, there often occurs a progressive sensitization leading to activation of uterine natural killer cells (NKa)…over time.

In such cases – provided that pregnancy occurs early on in the relationship (i.e., before NK cells become activated) – a normal pregnancy with full term delivery (as was the case with you) can and often does occur. Thereafter, repeated exposure of the uterine immune system to DQ alpha/HLA matching embryos, NK cell activation develops progressively over time. Once this happens, the woman will often start miscarrying, with the losses coming ever earlier (again as with you) until ultimately,  total implantation failure results (often regarded as “presumptive/unexplained secondary infertility”).  Please read the two blog articles I posted on IVFauthority.com (Immunologic Implantation Dysfunction Part 1 and Part 2)  in May 2011 as well as the one on Recurrent Pregnancv Loss.

The above could explain your situation. I suggest that you contact Reprosource (Boston, MA) or Reproductive Immunology Associates (Van Nuys, CA) and send your and your husband’s blood there for testing. Your blood should be tested for NKa (using the K-562 target cell test) and both your and your husband’s blood should be tested for DQ alpha and HLA genetic matching.  Once you have the results, we certainly should talk. Might I suggest that you call 800-780-7437 and set up a Skype consultation with me for 14 days after blood has been dispatched for the above tests. In the interim, please complete the attached questionnaire and send me all your old records for review.

Geoffrey Sher, MD

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[The patient underwent testing as I recommended and the results confirmed the presence of NKa as well as a partial DQ-alpha match. The letter below details my recommendations to the couple following our Skype consultation.] 

Dear Darla,

As we discussed yesterday, your test results indicate the presence of activated uterine Natural Killer Cells (NKa) in your system. In addition, you and your husband do indeed have a partial DQ alpha gene match. As I told you when we consulted, this means that one out of every 2 embryos (resulting from his sperm fertilizing your eggs) will match your DQa genotype and as a result, upon reaching your uterus, will elicit the activation of NK cells there. The treatment of NKa is an infusion of Intralipid combined with oral ingestion of corticosteroids to overcome the NKa that occurs in a situation involving DQ alpha/HLA matching (such as you have).  Since we presently have no way of determining whether the DQ alpha/HLA contribution to an embryo comes from you or from your husband’s contribution,  I believe that our best course of action would be to proceed with IVF and to transfer a single embryo per attempt. My reasoning is that if we transfer more than one at a time, a matching embryo would likely “muddy the waters” by activating uterine NK cells and thereby prevent the non-matching one from developing into a healthy pregnancy.

Bear in mind that even in the absence of IID in a woman of your age, each advanced embryo (blastocyst) would likely have no more than a 30% chance of resulting in a birth. So with a partial alloimmune match compromising half of your embryos, I would estimate the chance of a live birth per transfer at around half that number (i.e., 15%).  However, there is a way in which we could potentially double the chance of success in your case. This would require testing all your embryos for their chromosomal integrity (genetic “competence”) through CGH analysis and then transferring one chromosomally normal blastocyst at a time (under intralipid and corticosteroid cover) until a viable pregnancy occurs. I strongly recommend this approach for you.

Geoffrey Sher, MD

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Conclusion:

The patient decided to follow my recommendations and undergo IVF with CGH testing, combined with single blastocyst transfer. Eight (8) months later, after the second single blastocyst transfer, she conceived and subsequently gave birth to a full term baby girl without any complications.

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I recently received an email from a patient I will call “Beth” that illustrates the complex interplay of factors that need to be evaluated in a “typical” case of recurrent pregnancy loss.  It has elements of immunologic dysfunction, PCOS, secondary infertility, endometrial polyps, uterine lining problems, and genetic testing.  I have quoted the letter below, along with my response to her.

Hello Dr. Sher,

I would like to speak with you about my case and ask you a couple of questions about immune testing.  Now to tell you a little bit about me, I have polycystic ovarian syndrome (PCOS) but am not your typical PCOS patient.  I am 115 lbs, have no excess body hair, but do have high androgens. My local endocrinologist treats me for this and I am currently on Metformin 1000mg once daily.  I was never on Metformin for any of my IVF cycles except this past Frozen, so in other words, my PCOS was never treated while doing IVF stimulation or my first frozen cycle.

I am 35 years old and have had quite a long journey with infertility. My husband and I conceived our first pregnancy via clomiphene therapy.  I had a miscarriage followed by D&C for that miscarriage.  All of this happened prior to going to our first fertility doctor in 2006.  I went the IVF route after two consecutive early pregnancy losses, and because we have great fertility insurance.

 I did one freshIVF cycle (11/2006) which got cancelled due to ovarian hyperstimulation with its potential risks. We regrouped and did another fresh IVF cycle in January 2007.

Two (2) beautiful, fresh 5-day blastocysts were transferred and I temporarily had a positive pregnancy test (a chemical pregnancy). There was a 3^rd fresh IVF cycle in March 2007, where I propagated 15 embryos. CGH testing was done and three were normal. They were transferred and I now have a beautiful 5 year old son who was delivered by caesarean section.

May 2008 – I had a hysteroscopy to remove polyps and long retained products of conception. I had another hysteroscopy inMarch 2009, again for potential polyps. In May 2009 I underwent my 4th Fresh IVF cycle. Two blastocysts were transferred and another chemical pregnancy resulted.

Since May 2009 I have had 3 more hysteroscopies to remove polyps.

In May 2012 I did my first frozen cycle (FET), with one CGH-normal embryo, but I had trouble getting my lining thicker than 6.2mm, despite oral, vaginal and IM estrogen therapy. Needless to say I did not conceive.

A second FET was done 8 months later and one excellent quality, thawed 5-day blastocyst (not genetically tested) was transferred. In spite of supplemental estrogen therapy and two Neupogen uterine washes one week apart, my uterine lining maxed at 6.8mm. I did not conceive.

My RE has since suggested gestational surrogacy, but I am not ready to consider this radical step.  I have never tried Viagra vaginal suppositories, or any drugs other than Estradiol.

In November I was researching Neupogen washes on the internet and found information from another doctor.  I contacted him and ended up going to see him because I wanted input as to what might be possibly be going on with me that might explain MY  lining issues and recurrent IVF failure/losses. He thought that it all might be due to immunologic uterine factors and suggested that I undergo extensive and expensive immune testing. I am concerned about having so many tests done if not necessary. My husband and I are so blessed to have our son, but feel like God has another baby for us, with me carrying it myself. 

Thank you so much for your time.

Sincerely,

Beth (name has been changed for anonymity)

Following is my response to her:

Hi  Beth,

Thank you for your very detailed letter.

Though many of the factors you mention might point to an immunologic cause for your IVF failures, this, in my opinion, is not likely for the following reasons:

1. You did have a baby following one IVF procedure and this (although not always the case) virtually rules out autoimmune implantation dysfunction as the cause of your problem. There still could be an alloimmune issue, but in my opinion this is not likely to be the case. BY THE WAY…no matter what you might have been told, there is absolutely NO known link between immunologic implantation dysfunction and a thin uterine lining.
   
2. It is clear that with consistently having a maximum proliferative endometrial thickness of <8.0mm (the critical low), you have a significant uterine lining issue. My bet is that this is where your primary problem lies.
   
3. You do have PCOS (albeit without typical physical manifestations), and PCOS is commonly associated with an increase in LH biological activity that can result in increased ovarian male hormone/androgen (largely testosterone) production. This is largely a local effect which, because of a dilutionary effect, might not show up distally in the peripheral blood. The concentration of testosterone in the pelvic hypogastric venous blood can in fact be many times higher than in the peripheral blood where the levels can even be normal. The effect of increased uterine testosterone on endometrial proliferation (thickening) in response to estrogen can be profound and may conceivably result in androgen-induced down-regulation of  endometrial response to estrogen (estradiol) with a resultant poor endometrial response and a thin lining. I have seen this over and over again in women with PCOS or other conditions associated with increased LH-induced ovarian testosterone production (e.g. those with severely diminished ovarian reserve).You should know that vaginal Viagra therapy in such cases will often NOT help much.  If applicable in your case, the best way to deal with this issue would be to first down-regulate your LH over time and then stimulate with a very individualized protocol for ovarian stimulation, one that maintains a suppression of pituitary LH.
   
4. It is possible that your thin lining is due to endometritis associated with long term retention of products of conception. If this is so, then neither Viagra nor modifying the protocol of ovarian stimulation will help. This is something we would need to take into account and evaluate in advance.  

While I agree that it might be worthwhile evaluating you for auto/alloimmune implantation dysfunction, I suspect that these tests will be normal. I agree that there is no point starting off with a barrage of expensive tests. All that is needed would be to test you for Natural Killer cell activation (NKa) since regardless of the cause of an underlying immunologic problem, NKa represents the final common immunopathogenic pathway. You should request that an NKa test (the K-562 target cell test) be done on your blood.  If that does not test positive, then no further immune testing would be required.

However, if there is any suggestion of NKa, (only) then would I recommend further testing to identify/define a) any underlying autoimmune cause by testing Reproductive Immunophenotype (RIP), antinuclear antibodies (ANA), antiphospholipid antibodies (APA) and antithyroid antibodies (ATA) and, b) an alloimmune cause by testing both your and your husband’s blood to identify DQ-alpha and HLA gene matching.

By the way, there is absolutely no evidence that Neupogen uterine washes will improve endometrial proliferation.

Thank you for contacting me with your questions; I look forward to our consultation.

Sincerely,

Geoffrey Sher, MD

The above email and response are a good representation of the complexity of many infertility cases that I am presented with. I take personal pride in providing new insights to patients that have been through repeated losses and failures. This letter is a vivid illustration of the value of a second opinion in uncovering “hidden” factors that might be contributing to a couple’s difficulty in having a baby. 

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This month is ‘National Endometriosis Awareness Month’. Instead of discussing its medical aspects, I thought it more appropriate to discuss the personal side of endometriosis.

Endometriosis is a benign gynecological condition where the uterine lining (endometrium) grows on pelvic structures outside the uterine cavity. It is true that is ‘benign’ from that standpoint of not being a form of cancer or malignancy. However, it is a medical condition that has long-term, even lifelong implications. From a gynecological perspective, endometriosis can cause extremely painful periods, severe pelvic pain even without menstruation, painful intercourse, and infertility.

Any and all of these symptoms can affect a person’s quality of life. And unfortunately, curative treatment renders a woman sterile. Endometriosis can only be definitively diagnosed with invasive surgery; it is only with surgery that one can determine the severity of the disease and the extent of its damage. There is little correlation between the severity of endometriosis and symptoms being experienced. However, there is correlation with the extent of endometriosis and its impact upon fertility.

I, myself, have Stage IV endometriosis and have suffered from many of the symptoms that I listed above; however, I was just diagnosed a few years ago. Before my diagnosis, I had multiple pregnancy losses and secondary infertility (the inability to get pregnant after being able to conceive in the past). I underwent IVF multiple times to increase the likelihood of getting pregnant and delivering a healthy child but it never worked, even though I had a >50% chance of success with each attempt. Happily, I now have a wonderful daughter and family despite my reproductive history. These experiences have given me unique personal and medical insight into the implications of having endometriosis.
We know that endometriosis impairs fertility by causing scarring within the pelvis, thus interfering with the transport of an egg/embryo through the fallopian tube.

We know that peritoneal toxins associated with endometriosis reduce the ability of an egg and sperm to fertilize and thus IVF is often the treatment of choice (so that these toxins are avoided).

But what about lesser known mechanisms? Activated Natural Killer cells can cause decreased fertility potential in women with endometriosis. Interestingly, approximately 30% of women with endometriosis have activated Natural Killer cells. This form of immunologic implantation dysfunction is a theory proposed and successfully treated by Dr. Sher. In fact, the Sher Institute for Reproductive Medicine stands alone in its understanding, assessment, and treatment for immunologic implantation dysfunction in women with and without endometriosis.

I think back to my multiple pregnancy losses and failed IVF cycles, when no one was able to figure out what could have been the underlying problem. And while I wasn’t officially diagnosed with endometriosis until much later, I’m sure that I had some endometriosis (perhaps Stage I) at the time of my miscarriages and treatments. My failed treatments simply may have been due, in part, to activated Natural Killer cells…

In a way, I’m fortunate to have experienced the impact of endometriosis so that I can better understand a patient’s perspective. Better yet, by being a physician, I can test patients for immunologic implantation dysfunction and treat them appropriately.

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There is little doubt that there is an ever growing recognition and acceptance of the fact that uterine immunologic dysfunction can lead to “unexplained” infertility, implantation dysfunction, unexplained IVF failure, recurrent pregnancy loss (RPL), and even placental insufficiency. Although there are many autoimmune and alloimmune factors that contribute to such implantation dysfunction, in the final analysis it is the activation of uterine natural killer cells (NKa) (and possibly cytotoxic-T cells) with the release of toxic cytokines that so damage the “root system” (trophoblast) of the embryo that the pregnancy is either immediately rejected, or placentation is compromised, causing pregnancy loss.

There are several methods whereby NKa can be assessed in the laboratory. While methods such as immunohistochemical assessment of uterine NK cells and/or TH-1 and TH-2 cytokines have been used, the gold standard remains the so called K-562 target cell test. In this test, NK cells isolated from the blood through flow Cytometry are incubated with specific target cells and thereupon, NK cell killing is measured. It is important to bear in mind that measurement of NK cell blood concentration has little or no value in assessing NKa.

Currently, probably less than a half dozen Reproductive Immunology Laboratories in the U.S.A are capable of performing the K-562 Target cell test reliably. Both immunoglobulin-G (IVIG) and Intralipid (IL) can successfully down-regulate NKa in the clinical setting.

Presently, virtually all these laboratories compare NK cell activity before and after exposure to IVIG and/or IL. In my opinion, this does not make sense, since neither IVIG nor IL can immediately lower activation of already activated NK cells. The way these therapies achieve such NK cell down-regulation is based upon the way in which they are formed.

This is how it happens: So called “progenitor NK cells” reach the uterus early in the menstrual cycle where, under the effect of estrogen, they undergo proliferation. These “progenitor NK cells” are NOT the ones that influence implantation. This role is effected through their “offspring”, i.e., “functional NK cells” which they propagate after being exposed to progesterone. This is produced after natural or induced ovulation, or following progesterone hormone therapy.

Thereupon it takes approximately 5-7 days for these “progenitors” to spawn a sufficient number of “functional NK cells” at the implantation site to influence orderly implantation. It is by no coincidence that this aligns with the time that the embryo implants into the uterine lining (endometrium).

Neither IVIG nor IL is capable of significantly suppressing already activated “functional NK cells.” For this to happen, the IL/IVIG must influence “progenitor (parent) NK cell” activity. Thus it should be infused several days prior to ovulation or progesterone administration so that the down-regulated “progenitor NK cells” will propagate a sufficient number of normally regulated “functional NK cells” to be present at the implantation site 7 days later.

Even though most Reproductive Immunology Reference Laboratories still report NK cell activity (NKa) before and after IVIG or Intralipid is added to a specimen of activated NK cells, there is in my opinion no value in trying to assess the therapeutic potential of IVIG or IL therapy in this way. Moreover, such information can be misleading. Similarly, there is no real benefit in trying to assess the clinical effect of IL/IVIG immunotherapy by measuring NK cell activity in a woman’s blood sooner than 2 weeks after its administration. Even then, the value of such retesting is probably questionable.

In my opinion, it is very regrettable and unfortunate that so many patients are denied the ability to go from “infertility to family” simply because (for whatever reason) so many reproductive specialists refuse to address the role of immunologic factors in the genesis of intractable reproductive dysfunction. Hopefully this will change …and the sooner the better.

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This continues our series of IVF case studies. Here in our 8th case we discuss a couple who had experienced 22 previously unexplained IVF failures who had diminished ovarian reserve (DOR) plus immunologic implantation dysfunction (IID) and subsequently conceived when treated with an agonist/antagonist conversion protocolwith estrogen priming and selective immunotherapy to down-regulate activated natural killer cells (NKa).

Background
Christine, a 42 year old physician from Australia had endured 23 prior unsuccessful fresh embryo transfers over a period of more than a decade. By the time I got to know her she had severelydiminished ovarian reserve (her day-3 FSH was 26MIU/ml).

Follow-Up
After a lengthy telephone consultation with her, I urged her to send a blood sample from Melbourne, Australia to a reputable Reproductive Immunology Reference Laboratory in Southern California for testing to screen for immunologic implantation dysfunction (IID). It soon became apparent that she had an autoimmune thyroid condition (antithyroglobulin and antimicrosomal antibodies) along with activation of uterine Natural Killer Cells (NKa+). After controlled ovarian stimulation(COS) using an aggressive agonist/antagonist conversion protocol with estrogen priming, and pre-treating her immunologic implantation dysfunction (IID) with selective immunotherapy, I harvested just three eggs. We subsequently transferred two embryos to her uterus. She conceived in this cycle and gave birth to a healthy baby boy nine months later.

Commentary
This case shows that there is no merit in doing IVF over and over again in the face of repeated prior failures, without making a strong effort to determine the reason for such failures. In Christine’s case, by the time I saw her for the first time, she already had severely diminished ovarian reserve (DOR) as well as an immunologic implantation dysfunction (IID) linked to Natural Killer cell activation (NKa). We addressed the severe DOR by stimulating her with an agonist/antagonist conversion protocol plus estrogen priming and harvested 3 mature eggs (MII’s) and transferred 2 good quality embryos. We addressed the IID through selective immunotherapy by down-regulated her NK cell activity and corticosteroid therapy to establish a favorable uterine environment. She duly conceived.

This case also demonstrates that in women with severe DOR, diminished egg/embryo quality can in part be effectively by using an individualized approach to ovarian stimulation such as the agonist-antagonist conversion protocol with estrogen priming; LA10-E2V.

Addendum: It is important to understand that IVF is an ART-Science blend and not all practitioners agree on the same strategies. Thus, in the final analysis, it is important, after discussion with your personal doctor, to follow his/her advice to the letter.

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Preface: It frustrates me no end that so many couples who have failed to conceive following IVF are often glibly confronted with platitudes such as “It was just bad luck … so just try again,” and in the process are left “spinning their wheels,” feeling abandoned. While “bad luck” could indeed sometimes be a factor, this is not often the case, especially when, in spite of the transfer to the uterus of microscopically “good quality” embryos, the woman fails (often repeatedly) to conceive. The problem is further magnified when it comes to older women for whom time is running out because of an inevitable age-related decline in egg quality (“competency”), and in cases of diminished ovarian reserve (DOR) where the woman’s supply of eggs is rapidly becoming depleted. Most patients who have failed to conceive with IVF intuitively believe that something might have been overlooked in their cases and that, were the issue(s) to be identified, they could be remedied.

Frankly, given all of the good fortune and opportunity afforded me over a 30 year career in the field of IVF , I feel a strong compulsion to put my extensive experience to work where it can do most good and to offer it unconditionally to infertile patients. This is particularly relevant since several major medical advances that I and my colleagues introduced over the years could be applied to the diagnosis and treatment of many such problems, and make a real difference. These include:

a) In-roads made with regard to defining individualized protocols for ovarian stimulation
b) The Introduction of clinical Comparative Genomic Hybridization (CGH) embryo selection
c) The role of Immunologic Implantation Dysfunction (IID) in failed IVF

It is against this background that I have elected (for the foreseeable future) to offer detailed IVF telephone consultations, free of charge to all US and Canadian patients who are interested in my opinion, regardless of where they subsequently choose to be treated. Accordingly, I have designated specific times (daily) in my schedule for this purpose. Please call 800-780-7437 to schedule or submit the request form HERE.

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IVF treatment always exacts a profound emotional and financial toll on patients/couples. Needless to say, the financial burden is often crippling However, ask any woman who has undergone IVF and she will likely tell you that the emotional impact was by far the most devastating….especially when the IVF treatment cycle failed to bring her a baby.

The truth is that even in the simplest of cases (i.e. younger women who have normal ovarian reserve with fertile male partners), and in the most capable of hands, at best 50% will give birth to a baby following the transfer of 1-2 morphologically “normal” embryos. More than 70% will achieve success after two fresh embryo transfers. When this fails to happen, the question will invariably arise as to why the failure occurred.

Currently, in excess of 90% of the IVF patients I treat have at least one prior failed attempt before consulting with me, and more than 80% have failed IVF at least 3 times prior to seeking my services. I could cite many cases where patients have even endured as many as 10 or more prior IVF failures. But there is one case in particular that is permanently embedded in my memory and which highlights the importance of an individualized approach to treating infertility patients, especially when it comes to those with prior IVF failures.

The patient was a 42 year old physician who hailed from Australia. She had endured 23 prior unsuccessful embryo transfers over a period of more than a decade. By the time I got to know her she had developed severely diminished ovarian reserve (her day 3 FSH was 26MIU/ml). After a lengthy telephone consultation with me, I urged her to send a blood sample from Melbourne, Australia to a reputable Reproductive Immunology Reference Laboratory in Southern California for testing, to screen for immunologic implantation dysfunction (IID). It soon became apparent that she had an autoimmune thyroid condition (antithyroid antibodies) plus activation of uterine Natural Killer Cells (NKa+). After putting her on an aggressive agonist/antagonist conversion protocol (A/ACP) with estrogen priming and treating her with selective immunotherapy, I harvested (just) three eggs and subsequently transferred two embryos to her uterus. She conceived on this cycle and gave birth to a very healthy baby boy nine months later.

So then…what are the most common reasons for “unexplained” IVF failure, and what can be done to deal with them?

To adequately address these two all-important questions, we first need to recognize and understand that with the exception of poor technical skill in performing embryo transfer, IVF failure is virtually always due to one of the following two causes, which I will address below:

A. Embryo “Incompetence” (+/- 75% of cases)
B. Dysfunctional/Failed Embryo Implantation (+/- 25% of cases)

A. Embryo Incompetence
What is critical to understand here is that it is the chromosomal integrity (“competence”) of the embryo that is the main determinant of its ability to propagate a normal pregnancy. It is almost always the egg (rather than the sperm) that determines this factor. Only a mature egg (MII) that is numerically chromosomally normal (with 23 chromosomes – also known as a “euploid” egg) at the time of egg retrieval can propagate a “competent” embryo. No manipulation in the IVF laboratory, be it assisted hatching, embryo co-culturing, specialized fancy culture media, or even cytoplasmic transfer from a different (euploid) egg can cause an egg that has an irregular quota of chromosomes (aneuploid) to propagate a competent/euploid embryo (i.e. 46 chromosomes). Patients should be highly skeptical of any suggestion to the contrary. Simply stated, an embryology laboratory can only grow competent embryos from competent eggs.

Thus, egg competency at the time of egg retrieval will ultimately determine the ability to generate competent embryos for embryo transfer. By the time the egg is extracted, the “die has been cast” What this means is that aside from the woman’s age – which influences the percentage of her eggs that will have the potential to develop into euploid mature (MII) eggs following hormonal stimulation – the only manner by which we as IVF physicians can influence egg quality is by applying an individualized approach to ovarian stimulation. Without such an approach, egg development will often be compromised (especially in older women, in those with PCOS, and in women with DOR). Then, the hCG “trigger” would be much more likely to cause disorderly rearrangement of egg chromosomes, leading to a greater likelihood of egg incompetence (aneuploidy) and ultimately to incompetent embryos.

Today, through the use of full embryo chromosomal assessment (i.e. full karyotyping) using CGH, we can identify “competent” embryos for selective transfer. The use of this technique is both diagnostic (in that it allows us to determine whether the cause of IVF failure is embryo incompetence or an implantation issue) and therapeutic (in that we can thereupon selectively transfer only one or two embryos at a time and achieve almost a 70% pregnancy rate while virtually eliminating the chance of high-order multiples (triplets or greater). CGH embryo selection is of special relevance and value in cases of older women or those with DOR for whom “Staggered IVF” with embryo banking is of particular value.

Dysfunctional or Failed Implantation

Endometrial thickness (as measured by ultrasound) is described elsewhere. We previously have published that an ideal endometrium measures at least 9mm in thickness at the time of maximal estrogen stimulation. We have also pointed to the importance of excluding the existence of surface lesions that protrude into the uterine cavity (polyps, fibroid tumors or scarring) as they can, by creating an adverse uterine environment, lead to failed implantation. Only a hysteroscopy or a hysterosonogram (saline ultrasound) can diagnose the latter which needs to be treated surgically before embarking on IVF. A hysterosalpingogram (HSG) is too inaccurate to accomplish this.

Then there is the ever-important and (through either arrogance or ignorance) commonly overlooked issue of immunologic implantation dysfunction (IID) that should always be evaluated and addressed in cases of unexplained or repeated IVF failure. Frankly, since in the absence of Nka+, immunologic problems (regardless of cause) are not likely to cause IID, and given the fact that most of my IVF patients come to see me because of repeated failures in the past, I test almost everyone initially for Nka. If the test result comes back positive, we expand immunologic testing to look for the underlying cause. This having been said, I cannot overemphasize how important it is to always have a high index of suspicion regarding the possibility that failure could be due to IID in any patient who has had an unexplained IVF failure in the past.

To schedule a free telephone consultation with Dr. Sher, please call 800-780-7437, or fill out and submit the form HERE.

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It is an unfortunate reality that many IVF programs attach little importance to factors that affect embryo implantation in general, and immunologic implantation dysfunction (IID) in specific (see below). Perhaps the lack of attention given to evaluating IVF patients for factors that adversely affect the receptivity of the uterine lining (endometrium/decidua) is due to the fact that in humans, IVF failure and miscarriage are both four times more likely to be due to embryo “incompetence” than to dysfunctional implantation.Thus, a high measure of IVF success can still be achieved in spite of ignoring less common (and more complex) factors such as IID.

But for the 20% of IVF patients with problems relating to lack of endometrial receptivity, it becomes a different matter altogether. For them, the emotional, physical and financial roller coaster ride goes on and on. Often after “spinning their wheels” and enduring repeated IVF failures, many of them will be advised to move on to egg donation…only to fail there as well. Optimal implantation is not only important for embryo survival; it is also a major factor in determining normal intrauterine growth and development. As such, it is a major determinant of the very quality of life after birth.

Immunologic acceptance of the implanting embryo by the uterus of the mother is both highly complex and magnificent. Not only is it essential for pregnancy to occur, but it also sets the scene for our body’s own cells, tissues and organs to be shielded from attack by our own immune systems. For a moment, consider how, when confrontedby foreign proteins (bacteria, viruses, foreign tissue grafts/transplantation), the body’s immune system goes on the attack, but yet an embryo that is derived from proteins that come from another individual (the sperm or paternal antigen), usually safely implants in the pre-pregnancy uterine lining and then grows into a healthy baby.This phenomenon has come to be referred to as the “immunologic riddle” of pregnancy.

For such a complex arrangement to be foolproof would be without precedent in human biology. To argue that this system can never fail is in my opinion, an absurdity, bordering on arrogance. It can and does go wrong in about 15-20% of women with reproductive failure.When it does, it presents either as failed implantation (presumed by the patient to be infertility), as miscarriage, or (much less frequently) as placental failure and compromised fetal development or intrauterine death. It all depends on the timing, nature and severity of the immune assault.

It is well known that the reason the implanting normal embryo thrives in the womb is that unique immunologic adjustments convert the pre-pregnancy uterine lining (decidua) into a “privileged site” where the embryo and the fetus come to be regarded as the “body’s own” and as such are protected from immune attack. This initial acceptance of the embryo as “self” or “friend” rather than “non-self” or “foe” (in spite of it being composed partially of the father’s “foreign” cells), is one of the miraculous adaptations of nature, and is in large part responsible for our survival as a species.

As soon as implantation begins, the paternal genetic contribution to the embryo (so called DQ alpha genes) initiates asignal to the pre-pregnancy decidual immune system which thereupon determines whether the embryonic “allograft” should be welcomed as “friend” or be rejected as “foe” through immune attack. The process is referred to as “alloimmune recognition.”Given that with the exception of monozygotic twins, interpersonal differences in genotype are inevitable, it follows that maternal and paternal DQ alpha gene combinations will usually also differ in the vast majority of cases. Thus, preservation of the human species required that in spite of such immunogenetic dissimilarities, the immune system of the pre-pregnancy endometrium (decidua) evolutionarily adapt and recognize the embryo as friend rather than foe.

Upon reaching the uterine environment, the genetically “competent” embryo hatches and within 12-24 hours starts sending its root system (trophoblast) into the decidua. The trophoblast has both a villous (root-like) and an extravilous (diffuse) component. The extravilous trophoblast which diffusely permeates the decidua, expresses several so-called “major histocompatibility complex” (MHC) class-1 genes (e.g. histocompatibility leukocyte antigen [HLA]-C, E & G)].These HLA genes, (mainly HLA-G) regulate primarily two types of lymphocytes present in the decidua.These are: a) uterine natural killer cells (NK) and b) cytotoxic lymphocytes (CTL). NK cells comprise approximately 75% of decidual lymphocytes and CTL comprise about 10%. They both play a vital role in regulating the normal implantation process by controlling the penetration and functioning of the trophoblast.

The recognition of proteins as self (“friend”) or non-self (“foe”) is propagated by highly specialized immune lymphocytes known as Regulatory T-cells. These so called Treg cells can “turn-off” immune reactions even once they have been started by conventional immune cells. They play a pivotal role in the immune system’s ability to prevent rejection of an embryo whether due to an autoimmune or alloimmune response. Other immune cells known as “dendritic cells” introduce antigenic proteins to these Treg cells, whose concentration increases when the antigen is recognized as “friend” and decreases when recognized as “foe.” MHC (primarily HLA-G) signaling, through the Treg lymphocyte mechanism working in combination with other regulatory proteins, influences the production and release of so-called cytokines by the NK and CTL cells.

There are 3 varieties of cytokines, two of which play defining roles in the maintenance of implantation:The first is TH-2 cytokines, which encourage growth and expansion of the trophoblast and promote proliferation of blood vessels (angiogenesis). TH-1 cytokines promote destruction (cytolysis) of trophoblastic cells and also cause blood to clot (procoagulant effect).A balance between TH-1 and TH-2 cytokines is essential for normal implantation and development of the placenta (placentation). Over-activity (dominance) of TH-1, the hallmark of NK cell and CTL activation, leads to damage of the trophoblast, implantation dysfunction and reproductive failure.

Part 2 of this post will discuss the diagnosis and treatment of immunologic implantation dysfunction.

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Patients often ask “When is it time for me to stop doing IVF?”The answer I consistently give is that it is time to stop “when there is no remediable explanation for failure.”It is against this background that I submit that pre-cycle evaluation of a couple undergoing In Vitro Fertilization (IVF) is probably the most important step in the entire process, and becomes even more critical when it comes to evaluating a couple who has failed to conceive after undergoing 1 or more IVF attempts in the past.

The Seed-Soil Analogy

I have in the past stated that successful human reproduction is akin to the need when gardening, to establish an ideal “seed/soil relationship.” However, when it comes to reproduction, the “seed” is the embryo and the “soil” is the uterine lining.As with horticulture, a successful outcome requires planting a “good seed” in a “good soil.” In the case of IVF, a good seed is analogous to what we refer to as a “competent” embryo. This is an embryo that has the proper number of chromosomes (euploid) and has an optimal chance of developing into a healthy baby.A “good soil” is analogous to a receptive endometrial lining (one that will allow normal and healthy implantation to be established). So, proper (re)evaluation of a woman undergoing IVF requires a critical (re)assessment of those variables that affect embryo competency and endometrial receptivity.

A. Evaluating the Factors That Affect Embryo Competency (The “Seed”)

1. Age

The woman’s age during IVF is the most important factor affecting the chromosomal integrity of her eggs.This in turn, is central to the ability of the egg to develop into a “competent” euploid embryos post-fertilization.The “competence” of an embryo is determined largely by the chromosomal integrity of its egg of origin. Only a euploid eggcan propagate a “competent” embryo and it is the age of the woman that determines the likelihood of any egg being euploid.The percentage of a woman’s eggs that are euploid decreases progressively with advancing age beyond 35.At age 30, slightly less than 1 in 2 of eggs will be euploid; at age 40 about 1 in 6-8, and by her mid 40’s, less than 1 in 10 eggs will be chromosomally normal eggs.Cells that have an abnormal quota of chromosomes are referred to as aneuploid. A “normal” (euploid) mature egg has 23 chromosomes. Anything more or less than that number makes the egg aneuploid and such eggs will invariably propagate “incompetent” aneuploid embryos which will either fail to implant, briefly implant and then be lost as a miscarriage, or (albeit infrequently) propagate a baby with a chromosomal birth defect such as Down’s Syndrome. It follows that the woman’s age must be taken into consideration when discussing the likelihood of a successful IVF outcome.

The older the woman undergoing IVF, the more difficult it becomes to maintain an ideal ovarian hormonal environment that would favor proper egg development and thus, the greater will be the imperative to modify the protocol of ovarian stimulation in order to avoid egg maldevelopment (that is more likely to occur in an abnormal environment) and an increasing likelihood that following the hCG “trigger” (that initiates chromosomal segregation) the “mature” egg will turn out to be aneuploid (see my post on an Individualized Approach for Ovarian Stimulation).

2. Ovarian Reserve

Approximately 6-8 years before the onset of menopause, the number of eggs available declines more rapidly, to the point that a woman progressively develops resistance to fertility drugs.This period of diminishing ovarian reserve (DOR) is known as the climacteric and is characterized by progressively rising basal blood FSH levels as well as by declining AMH and Inhibin B levels.The climacteric usually begins in the late 30’s to the mid 40’s but it can and often does occur sooner.

With DOR goes a change in ovarian response to hormonal stimulation and thus it becomes even more important to individualize the protocol of ovarian stimulation in such cases.

3. Sperm Quality

Male sperm dysfunction accounts for about 50% of infertility.In most cases, it is very difficult to reverse through medical or surgical intervention. When it comes to embryo competence, the egg plays a far greater determining role than does the sperm.However, in cases of male infertility, the contributing role played by the sperm in causing embryo aneuploidy increases significantly. There are circumstances where surgical or medical treatment can improve sperm quality significantly:

• Some men who have blocked sperm ducts or a fluid collection around one or both testicles (hydrocele) might benefit from surgical correction, while those with a collection of varicose veins around their testicles (varicocele) might benefit from surgical or radiological occlusion of the spermatic vein(s).

• While the egg plays a far greater determining role in embryo competence than does the sperm, in cases of significant male infertility, the role of the sperm increases significantly in this regard.

4. Genetic/Chromosomal Factors

Certain chromosomal and genetic abnormalities involving the man or the woman can thwart successful IVF.In approximately 1 out of 200 cases a balanced translocation (where part of one chromosome is exchanged with that of another) will cause unexplained IVF failure or miscarriage.This is worth looking for in some cases.There are also cases where there is a deletion of part of the chromosomes in the sperm or in the egg that can cause the same problem.Detection of such rare genetic events requires In certain cases where there is a low sperm count and motility, the cause may be related to understimulation of sperm production.In such cases the man might have a low blood FSH level.In such cases, treatment with medications such as low dose clomiphene or letrozole for a period of about 3 months (the sperm cycle) will sometimes result in a marked improvement in sperm function.In other cases, administration of FSH and/or LH medications over a period of 3 months can also be helpful (see my post on Enhancing Sperm Production).

B. Evaluating Factors that Affect Uterine (Endometrial) Receptivity (“The Soil”)

1. Thickness of the Uterine Lining

Measured at the time of the hCG trigger, the thickness of the uterine lining is also a very important factor.A lining of less than 9mm in thickness is suboptimal, while a lining under 8mm is usually totally inadequate.It is very important to recognize this fact because, just as the roots of a plant cannot develop adequately if it is planted in a thin layer of soil, so the embryo’s root system (trophoblast) cannot take proper hold or function adequately if the lining is too thin.Today, through the administration of medications such as Viagra for the uterine lining, estrogen and anti-prostaglandins (e.g., aspirin), it is possible in many such cases to improve the lining.However, when as a result of uterine inflammation or surgical trauma to the a thin inner (basal) germinal layer of the endometrium, such treatment will often be ineffectual, necessitating the use of a gestational carrier (surrogate).

2. Endo-Uterine Pathology

The presence of small surface lesions that protrude into the uterine cavity can interfere with embryo implantation. These can be (and often are) missed, unless proper inspection by a hysterosonogram, hysteroscopy or an MRI is done.The use of a dye X-ray test (hysterosalpingogram) is inadequate to identify small endometrial polyps, or small fibroids (see this article on Uterine Fibroids).

3. Immunologic Implantation Dysfunction (IID)

This is often a cause of “unexplained” IVF failure (in about 30% of cases) and must be looked for.Here, autoimmune rather than alloimmune factors (the latter more commonly results in early miscarriage), are usually the cause.Effective treatment of immunologic infertility is available.I have personal experience with many cases where using selective immunotherapy, I have successfully treated women who previously had failed to achieve viable IVF pregnancies after more than 10 consecutive attempts (and in one case more than 20 prior IVF failures had occurred). It is important to bear in mind that resorting to the use of donor eggs does not offer a solution in cases of immunologic implantation dysfunction.

To their own discredit, many fertility doctors have hitherto denied or even discounted the role played by immunologic factors in implantation failure and have even discredited the use of selective immunotherapy in such cases. In my opinion, in this attitude stemmed from a desire to maintain a competitive edge, since until recently, successful treatment of immunologic implantation dysfunction often required the administration of a blood product known as immunoglobulin-G (IVIg). The administration of this product was very expensive (up to $4,000 per infusion, and more than one administration was often required), and it sometimes caused unpleasant side-effects. In addition patients often expressed fear that because IVIg is a blood product, its administration might lead to the transmission of HIV and hepatitis viruses. The fact is however, that this concern was was unfounded because FDA-approved IVIg products are all screened for viral contamination and thus are safe in this regard. Against this background doctors were fearful that prescribing IVIg treatment (while others denounced it) would put them at a competitive disadvantage.

All this changed with the recent introduction of a product called Intralipid (IL), which has largely replaced IVIg for the treatment of immunologic implantation dysfunction. The reasons for the change of heart are that unlike IVIg, IL is very inexpensive (less than $200 per infusion), is safe, and is free of significant risk or side effects and most importantly, IL is equally effective for the treatment of immunologic implantation dysfunction . Perhaps not surprisingly, the low cost and minimal risk associated with IL therapy, bolstered by an ever increasing demand on the part of IVF patients that they be assessed and selectively treated for immunologic issues, has led to a dramatic increase in the number of RE’s that now test for immunologic implantation dysfunction. In fact, many of the naysayers now strongly advocate the use of selective immunotherapy in such cases. Simply stated, enlightened self-interest has now made it popular and convenient for critics to become advocates. Be that as it may, to ignore the fact that immunologic implantation dysfunction is an important cause of “unexplained IVF failure” is, in my opinion, to deny many women the opportunity to go from “infertility to family”. (See my post on Immunologic Implantation Dysfunction).

A few additional considerations:

As far as the embryo is concerned, a careful evaluation of its appearance microscopically and its rate of development is vital.As an example, an embryo that fails to divide to the 6-9 cell stage of development within 72 hours of fertilization is usually “incompetent.”In the same manner, embryos that develop beyond the 10 cell stage within the same time period are growing too fast and are very often also incompetent.We and others have pointed out that embryos failing to reach the expanded blastocyst stage within 6 days of fertilization are, in more than 95% of cases, aneuploid and would not have resulted in a pregnancy anyway.Also, embryos whose cells (blastomeres) are very discordant in shape and size, or embryos that have numerous small cell fragments disseminated throughout their substance (fragmented embryos) are also far more likely to be “incompetent.” While the age of the woman plays an important role in determining embryo development, so does the protocol of ovarian stimulation.It is in regard to the latter where we as treating physicians can play a very important role.

I have previously pointed out how individualizing the protocol of stimulation for IVF is central to optimizing the environment in which the egg develops, and hence the quality of the embryos it propagates.This is even more critical in woman with DOR, those with polycystic ovarian syndrome (PCOS) and in older women.I cannot emphasize strongly enough how important it is to assess the protocol of stimulation in all cases where there is deemed to be poor embryo quality (see my post on an Individualized Approach for Ovarian Stimulation).

Finally, there is the issue of carefully evaluating embryos for chromosomal integrity (karyotyping).Here the relatively recent introduction of Comparative Genomic Hybridization (CGH) for egg and embryo chromosomal analysis, is a game changer.A “CGH-normal” embryo transferred into a receptive uterine environment has about a 65-70% chance of producing a viable pregnancy regardless of the age of the egg provider.Unfortunately, microscopically “good-looking” embryos – even those that make it to the blastocyst stage – are not necessarily always “competent or euploid, and this fact serves to underscore the need for CGH analysis, especially in cases where there is unexplained IVF failure.(see my post on CGH Egg/Embryo Selection)

It is important to realize that it is often difficult or even impossible for women in their mid-40’s to produce the chromosomally normal eggs necessary to propagate euploid (CGH normal) embryo.This serves to explain why older women are less likely to conceive, even when their embryos appear to look normal under the microscope, and why the selective transfer of CGH-normal embryos should be the goal.(Please refer to the articles on the merits of embryo banking).

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