How to Discover and Address Repeated Embryo Implantation Failure
Repeated embryo implantation failure is an extremely frustrating condition for both patients and clinicians — mainly because the etiology is so often unknown. However, some causes are discoverable and able to be addressed, giving patients better chances for in vitro fertilization (IVF) and implantation success.
Lifestyle Habits
During an initial consultation, physicians should obtain a full personal medical history from the patient and any male partner or sperm donor. Healthcare providers should build a positive rapport with patients from the beginning to encourage them to provide a transparent and thorough history.
Alcohol consumption, smoking and drug use have been shown to affect fertility, including oocyte and sperm quality and quantity. To date, there is no acceptable range of alcohol consumption when trying to conceive, so suggesting moderation may not be enough to prevent gamete damage, cautions a study published in Fertility Research and Practice.
Physicians should also counsel patients on the importance of having a balanced diet, getting enough sleep and not overexercising. Making all of these changes could improve IVF outcomes.
Obesity
One study published in the journal JBRA Assisted Reproduction found obesity to be a major cause of repeated embryo implantation failure. If this is not already a clinic standard, weigh patients and any male partners at fertility consultations and discuss how body mass index (BMI) can affect reproductive outcomes.
Provide a list of local options for nutritionist and dietician referrals, preferably ones that accept insurance. A personalized nutrition plan helps patients reach the ideal BMI range without the burden of figuring it out themselves and possibly becoming burned out or stopping treatment. Obtaining advice from a professional can also help patients avoid dangerous crash diets or developing an eating disorder in their quest to lose weight.
Low-Quality Gametes
Sperm quality is easily analyzed through semen analysis. This should be conducted at or immediately following the initial consultation. Depending on the results, a patient may be advised to see a reproductive urologist.
While techniques using genomics and artificial intelligence are promising, there is currently no foolproof way to examine oocyte quality without retrieval, according to research published in F&S Reviews. Once an oocyte is retrieved and in the lab, embryologists can observe the shell and coloring, among other factors, to determine the quality.
Some poor-quality oocytes do not fertilize; some that fertilize do not become blastocysts. Some blastocysts test genetically normal but are still of poor quality, increasing the likelihood of repeated embryo implantation failure.
Prospective parents may be aware that oocyte quality declines steeply with age. However, younger patients can also have poor quality oocytes and are often surprised by this diagnosis.
Some supplements, such as ubiquinol and dehydroepiandrosterone (DHEA), have been shown to improve oocyte quality, according to research published in Reproductive Biology and Endocrinology. After examining the patient's ovaries using ultrasound and reviewing a hormone panel, doctors should determine whether or not these supplements may prove helpful.
Thrombophilia
Adding a thrombophilia panel to the typical infertility workup could prove beneficial. Although more research is needed, studies such as one published in Human Reproduction have shown that women with thrombophilias — such as antithrombin III deficiency, factor V Leiden, methylenetetrahydrofolate reductase deficiency and prothrombin deficiency — experience repeated embryo implantation failure at much higher rates.
Research published in the Open Journal of Obstetrics and Gynecology found that low-molecular-weight heparin may improve the uterine environment and the likelihood of implantation. Discuss the pros and cons of this treatment with patients and arrive at a decision together about the best path forward.
Uterine Factors
Uterine abnormalities — such as congenital uterine anomalies, endometrial polyps, submucosal fibroids or intrauterine adhesions — are a huge contributor to repeated embryo implantation failure.
Start with saline infusion sonography (SIS) to observe the uterine environment. If there are any areas of concern, follow up with a hysteroscopy. Discuss with the patient in advance which abnormalities can be addressed with an additional procedure (such as radiofrequency ablation for fibroids) and which may require a more involved surgery (such as some Müllerian anomalies).
Adnexal Pathologies
Hydrosalpinges are another condition that may hinder implantation. When a patient's fallopian tubes are filled with fluid that leaks into the uterine cavity, it is theorized that the quality of the uterine lining may decrease, the environment may become toxic or the fluid may "wash out" the embryo altogether.
Reproductive endocrinologists may be able to detect a possible hydrosalpinx during the initial transvaginal ultrasound or SIS exam. However, a hysterosalpingography could be necessary, followed by a laparoscopy to remove one or both fallopian tubes if a hydrosalpinx is confirmed.
Providers should conduct a thorough workup to identify any possible causes of repeated embryo implantation failure. Be honest but empathetic with the patient or couple about the prospect of implantation moving forward so they can make an informed decision about further treatment options.
