WHY AM I NOT GETTING PREGNANT?

I hear this question every day numerous times, and although the question is simple, the answer is not. The simplest way of looking at things is this: You need a healthy embryo to be placed into a healthy uterine environment. If you have this, then you are likely to have success.

In the majority of scenarios, the uterine lining or endometrium is not the culprit. Since the advent of embryo genetic testing, we have determined that the majority of even very normal appearing embryos are chromosomally abnormal (aneuploid). This came as a bit of a surprise to most infertility specialists who thought that a “normal” appearance was a strong predictor of embryo health.

These aneuploid embryos usually do not implant, but about 25% of the time they will, and can endure from a few hours or until full-term. Most however, will miscarry somewhere before 10 weeks. If one were to do a D&C procedure and screen the chromosomes of the tissue retrieved, it would reveal the particular chromosomal error.

Given the fact that abnormal pregnancies can indeed implant and create a significant degree of emotional grief and time loss, I prefer to move to IVF with embryo screening (called preimplantation genetic screening or PGS) in patients who have had multiple treatment failures. By doing this, one can avoid transferring abnormal embryos and minimize the risk of miscarriage and the turmoil that accompanies it.

If one screens embryos, one can not only discern if the embryo is normal or abnormal, but if the embryo is abnormal one can also discern if the abnormality came from egg, sperm, or both. This information is helpful in determining why things have not been working and can guide one into future directions, including the use of potentially healthier sperm or eggs from anonymous donors.

Although the nature of the IVF protocol can be helpful in improving one’s odds of achieving a healthy embryo to a certain degree, one often has to hope for a bit of luck as well because in any given month one might have a better or worse pool of eggs to work with than the months surrounding it.

If the uterus is the problem, it can be because the intrauterine lining or endometrium is insufficiently thick and fails to provide enough substrate for implantation. This tends to happen in patients with uterine trauma as can occur after D&C procedures, intrauterine infections, or uterine surgery such as fibroid removal (myomectomy). Luckily, this can frequently be helped with corrective surgery (scar resection) or the use of medications (sildenafil) or acupuncture to improve uterine blood flow.

Another potential cause of implantation failure is the presence of underlying autoimmune or alloimmune dysfunction (usually the former) associated with uterine Natural Killer (NK) and/or T-cell activation. In younger women, at least 40% of blastocysts are chromosomally normal, so when a woman in this category suffers multiple miscarriages or failed IVF cycles, immune factors can be a common culprit. These can many times be addressed through selective immunotherapy (using steroids and/or intralipid therapy) which will often result in a viable pregnancy. In fact, immunologic implantation dysfunction is a relatively common factor in women with “unexplained” IVF failure – especially younger women who have morphologically normal and/or CGH-normal embryos transferred.

Sometimes the endometrium is sufficiently thick, but it is not “receptive” or in sync with the developmental stage of the embryo. This can be detected by performing an endometrial biopsy in the luteal phase of the menstrual cycle and analyzing the tissue microscopically for the presence or absence of certain proteins (integrins, cyclins) associated with implantation. Evidence suggests that receptivity issues are best treated with medications that lower estrogen and “reboot” the uterine lining such as leuprolide or aromatase inhibitors.

Given all the issues one can look for, I often favor a two-stage approach, one in which we first perform IVF with PGS to make sure we have at least one or two chromosomally normal embryos to work with (i.e. “good starting material”), and then on to stage two, in which all necessary interventions are undertaken to afford the most hospitable uterine environment for those embryos.

Responses to "WHY AM I NOT GETTING PREGNANT?"

1. sharon wilson says:

   sharon wilson says:

   February 2, 2013 at 3:11 pm

   My wife and I have been trying to start a family. We been trying but we haven’t had any luck just yet. My wife have done two iui cycles so far, both times before it was time to take a pregnancy test the day before she got her period. What I would like to know is; are we doing the trigger shot to early or not timing it right? Each time she takes the trigger shot the day before the procedure instead of 36 hours before the process. What is the best way to go about with the trigger shot? The doctor that does our process says that everything be looking fine even the eggs when she takes the medicine and we do the ultrasound but; however it fails. Also I wanted to know about the Micro-IVF is it the same as an usually IVF?

   Reply
2. • Geoffrey Sher says:
     Geoffrey Sher says:
     February 2, 2013 at 6:22 pm

     Ovulation ordinarily takes place 38-42 hours post-hCG trigger. We usually therefore perform egg retrieval about 36 hours after the trigger. BUT with IUI we would do the initial insemination earlier than that. Remember that sperm can survive in the reproductive tract for days and we certainly want to do the insemination prior to ovulation. If it is done too late, itr wont work.

     As for micro-IVF, I have an article on that subject posted on this blog . Yes for those who qualify fore micro-IVF, success is the same as with regular IVF.

     You might consider calling 800-780-7437 to set up a nconsultation to discuss nyour bcase with me.

     Geoff Sher

     Reply
3. • Mari says:
     Mari says:
     February 25, 2013 at 6:19 pm

     I have a 12 y/o daughter and tried to conceive again when she was 3 y/o but was unable. In 2005 I tried a treatment of iVF and it didnot work. I continuously tried to get pregnant naturally but to no avail. I alway think about it and I am getting older and scared I will not be able to have any more kids. I am a preschool teacher and love kids, I also have a kidney transplant.. My doctors medically cleared me and told me I can try to get pregnant if I want to, but til this day I haven’t been able to get pregnant again. Can you help?

     Reply
4. • Geoffrey Sher says:
     Geoffrey Sher says:
     February 25, 2013 at 8:15 pm

     We would need to talk Mari. Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

     Geoff Sher

     Reply
5. • tyisha says:
     tyisha says:
     April 8, 2013 at 1:38 pm

     Me and my husband has been trying for 4yrs
     my gyn says im ok but she doesnt do any studies on me
     I tried using birth control and skipping a pill but nothing
     Works please doctor help us

     Reply
6. • Geoffrey Sher says:
     Geoffrey Sher says:
     April 8, 2013 at 5:12 pm

     Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail

     Geoff Sher

     Reply
7. • Ann says:
     Ann says:
     May 16, 2013 at 2:36 pm

     I have had extensive fertility testing over the past year and everything came out completely normal. I have multiple sclerosis and I was finally able to get a doctor to do an immune work up which revealed both anti-thyroid and anti phospholipid antibodies.

     with this information is IVF my only option if I haven’t been able to get pregnant at all?

     also, my husband’s testing came out perfectly normal as well.

     Thanks

     Reply
8. • Geoffrey Sher says:
     Geoffrey Sher says:
     May 16, 2013 at 5:33 pm

     You need testing for natural Killer cell activity (K-562 target cell test). If +ve, you need IVF. Please go to the home page of this blog, www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.

     1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

     2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

     3. “Agonist/Antagonist Conversion Protocol”

     4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

     5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

     6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

     7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

     Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail

     Geoff Sher

     Reply