Recurrent Unexplained IVF Failure with “Good Quality” Embryos

30 Apr
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The following is a case study of a recent patient that came to me for treatment. 

CJ, a 34 year old, and her husband RJ (age 35) presented to me with a six-year history of infertility. Based on semen analysis, RJ, who had initiated two pregnancies in a prior relationship, was found to be perfectly fertile. CJ had been married before and in that relationship, had also experienced 2 years of infertility. Of interest is the fact that CJ’s first husband remarried, and he and his new partner had since parented two children….So clearly, this was a female fertility issue.

CJ had had undergone a fertility evaluation and had been found to be ovulating normally, to have patent Fallopian tubes, and to have normal ovarian reserve. She had undergone a laparoscopy and hysteroscopy which revealed stage 1 (early) endometriosis and a normal uterine cavity.

CJ and RJ had gone through four IUI’s. The first two were with clomiphene stimulation and the last two with gonadotropins. Ovulation had been confirmed in all four stimulation cycles, but no pregnancy resulted.

Subsequently, the couple went through three fresh IVF attempts and two frozen embryo transfers (FETs). In each of the five embryo transfers, 2 well expanded, cellular, high quality blastocysts were transferred but no pregnancy occurred.

Their prior RE suggested that the reason for the failures was likely due to an unexplained egg/embryo issue and recommended another cycle of IVF, this time with CGH chromosome analysis being performed on all embryos, followed by the transfer of one or more embryos deemed to be chromosomally “competent” (CGH-normal).

I saw the problem differently. Here was a young woman with a male partner of proven fertility. She had a total of 8 high-grade blastocysts (as determined by microscopic analysis) transferred to an anatomically normal uterus, with a good endometrial lining, and yet had not even conceived once. Since in general, one out of every two of her eggs/embryos should be chromosomally normal and each chromosomally normal embryo should propagate a live birth 60-70% of the time, I concluded that there had to be an underlying implantation dysfunction that was preventing these embryos from attaching to the uterine lining.

Moreover, since 30% of women who have endometriosis, regardless of its severity, will have activated uterine natural killer cells (NKa) that could thwart implantation, it seemed to me that immunologic implantation dysfunction (IID) was the most likely explanation for CJ’s hitherto “unexplained” IVF failures.

We tested CJ through Reproductive Immunology Associates (RIA), Van Nuys, CA. and the NKa test (K-562 target cell test) result came back positive for activated killer cells. She was also found to have antiphospholipid antibodies (APA).

Treatment and Outcome: CJ and RJ underwent IVF at SIRM. We harvested 12 eggs. Nine were mature and all were fertilized by ICSI, resulting in nine embryos, four of which developed into expanded, good quality blastocysts. Two blastocysts were vitrified and banked and 2 were transferred fresh to CJ’s uterus. She conceived and subsequently gave birth to a healthy baby girl at term.

About 15 months later, CJ returned for a frozen embryo transfer (FET), using her remaining frozen blastocysts. She conceived another baby girl and is due to deliver later this year.

Commentary: Whenever confronted with repeated “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.

The most common causes of Implantation dysfunction are: a) a “thin uterine lining” b) a uterus with surface lesions in the cavity (polyps, fibroids, scar tissue) and c) immunologic implantation dysfunction (IID). It was detection of the underlying IID problem that enabled NJ and RJ to go from “infertility to family”

Implantation dysfunction is a common cause of repeated “unexplained” IVF failure with good embryos. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women.

103 Comments

  • marwa says:

    what was your treatment in this case?

    • Geoffrey Sher says:

      My website has changed. The new site is at http://www.sherIVF.com where I host and populate new and updated blog articles . The blog can also be accessed directly by going to http://goo.gl/4hvjoP. I currently respond to posts on this new site

      To find and follow updated and new blog articles and to post questions or comments, please use this new venue. I promise to respond promptly.

      NOTIFICATIONS:

      1. About my Intended Retirement:
      After 35 years in the field of Assisted Reproduction (AR), the time has finally come for me to plan my retirement from full-time clinical medicine. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at: 702-533-2691 or Julied@sherivf.com You can also apply online at http://www.SherIVF.com.

      2. The 4th edition of my newest book ,
      “In Vitro Fertilization, the ART of Making Babies” is now available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

      Geoff Sher

  • Phill says:

    Well how do I start upon having numerous amounts of tests and three miscarriages the result came that we needed to go for ivf for the next stages of our long painful journey.
    Some of the eight ivf implants using donor eggs a couple got to the heartbeat stage but sadly We never got past the twelve week stage some never even took we have had the medication changed upped but to no avail. We have told them about the simple cysts which they keep measuring and monitoring .We have spoke about the fibreoids but for a while now they have not mentioned them. Before the ivf we had them removed and she got pregnant naturally but which later failed due to text results which sent us down to seek ivf using donor eggs . We now are due to go for a further appointment to see where to go now but I think we need another opinion on what to do next.
    Now I have given you a basic run of our journey what would your advice be?
    We have read various articles about natural killer cells and implementation disfunction but it’s basically over our heads ,any thoughts?

    • Geoffrey Sher says:

      I unfortunately do not respond to posts on this site any longer. Kindly-go to http://goo.gl/4hvjoP and re-post your question/comment there, and I will respond promptly.

      I look forward to interacting with you!

      Geoff Sher

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