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Implantation Failure No Longer a “Black Box”

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Written in Partnership with Dr. Michael Feinman, HRC Fertility, December 14, 2015

By definition, IVF failure represents implantation failure. It is also reasonable to assume that longstanding unexplained infertility also represents a form of implantation failure. It is likely that over time, eggs are getting fertilized and embryos are reaching the uterus, and these embryos are failing to implant due to egg or sperm issues, or the uterine environment.

While much of implantation continues to be a mystery, it is no longer a “black box.” In fact, there has been enough progress to justify some testing in women who have repeated IVF failures and infertility that does not respond to conventional treatment.

Preimplantation Genetic Screening (PGS)
Day 5 embryos (blastocysts) can be sampled and tested to detect chromosomal abnormalities like Down Syndrome. While PGS does not improve pregnancy rates, it does help rule out this important problem as a cause of IVF failure. It is helpful to know that normal embryos are being obtained before looking for or treating other causes of implantation failure.

When tubes become blocked at their far ends, they can fill up with fluid and are called a hydrosalpinx. Repeated studies have shown that the presence of a hydrosalpinx lowers IVF success rates by 50%. It is believed that the fluid in the tube leaks back into the uterus and adversely affects the environment. Most women have both tubes affected. Most doctors advise removing these diseased tubes. A hysterosalpingogram (HSG) or x-ray dye test readily diagnoses this condition. It is surprising how many women have not had this test prior to starting IVF treatment.

Uterine Evaluation
It seems obvious, but it is important to make sure the uterus is shaped normally and does not contain growths like polyps or fibroids. An HSG, hysteroscopy, or sono-hysterogram are suitable tests. In our experience, a sono-HSG is less likely to detect a partial septum. Septums reduce pregnancy rates and cause miscarriages. They are readily removed through a hysteroscopic procedure. If a septum has been ruled out in the past, a son-HSG is usually adequate.

Endometrial Biopsy Tests
Over the years, a number of endometrial biopsy tests have been devised that look for markers of normal implantation. A recent version called the “Endometrial Receptivity Assay” (ERA) also provides a solution for the problem. According to the medical literature and our experience, 20 percent of infertile women have a correctable abnormal result.

Immunological Testing
This represents the most controversial area of testing, because despite years of discussion and hundreds of publications, it has been hard to get well-designed controlled studies done. However, there are probably a small group of women who do have an autoimmune response to pregnancy or reject their partner’s embryos. It is important to speak with a doctor who is experience with this testing to avoid over-testing.

What About the Men?
Men can also contribute to embryo issues, and a variety of tests have been developed to see if sperm issues adversely affect embryo viability. A popular example is the DNA Fragmentation Test, which is relatively affordable, available and performed on frozen semen. Studies have shown that high levels of fragmentation are associated with lower spontaneous pregnancy rates, higher miscarriage rates, lower fertilization rates with conventional IVF, and lower implantation rates.

While some controversies persist regarding the true value of some of the tests and treatments, many women with repeated IVF failures and longstanding infertility can still enjoy success if the above problems are addressed.


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