Having an embryo transfer or an IUI fail can be anywhere from disappointing to utterly devastating and like the world just fell apart; yet, the world keeps going in an eery and heartbreaking way. There’s nothing I can write to take those feelings away. They’re your feeling to move through. Eventually you will make decisions about next steps and when you do will depend on how time constrained you feel and how you like to plan. Some people even plan before a loss is confirmed.
Before you dive into the causes, let me share this with you.
1. This is not your fault.
The transfer may have failed but you are not a failure and you didn’t cause this. You took on the fertility treatment as an attempt to get pregnant but it doesn’t guarantee a baby. It can be a long road and that doesn’t mean anything about who you are or what you deserve.
2. If the fact that this transfer means that you’re closing the door on your options, I’m so sorry.
I’m so sorry if this was your last attempt with fertility treatment, or your last attempt at this type of treatment (for example now you’re deciding whether to try IVF after a failed IUI), or if this means you’re closing the door on having a child all together. I really am. Please find support, and that could include a Facebook support group or a professional like me if you’d like to talk, because you are not alone in this transition and it can be smoother when you connect with the right people or person.
3. If you’re attempting again, there are countless options to consider.
Usually with one failed IUI your fertility doctor will suggest you try again but that’s very specific to you and your situation and part of your decision making. If you’re doing IVF/ICSI and had one failed transfer, there is usually a different conversation if you’ve had more than one transfer fail, which is called recurrent implantation failure (RIF). That said, whether you’re doing IUI or IVF, an option that you can do at home is to put in place a stress reduction plan. Changing that up is proven to make the process easier, help you make decisions faster and potentially have an impact on implantation success (but there’s no clear evidence of the latter). Another option is to try laser acupuncture or acubalance, talk to your doctor about taking baby Aspirin, doing ICSI, intralipid infusions, see a Naturopath, see a fertility coach, and many more that are outlined below. This list is just scratching the surface.
Lastly, please remember that I am not providing medical advice below. Consult your doctor to get the medical advice.
Reasons a transfer failed
Chromosome issue. The most common reason for implantation failure and also the most common cause of a chemical pregnancy or miscarriage is chromosome issues. For embryo transfers, PGT-A testing reduces this risk according to many recent studies and fertility experts. If you did PGT-A and transferred a ‘normal’ or euploid embryo and it still failed, then chances are it’s something else, but that’s also not a guarantee. If you have untested embryos then you have three potential options: 1) thaw and do PGT-A and then refreeze your embryo and then thaw again for transfer is an option 2) use PGT-A for a future round 3) or transfer any additional embryo(s) and hope that it’s euploid or a mosaic that is compatible with life.
Egg quality issue. Egg quality is different than chromosome issues. Egg quality does overall decrease by age similar to chromosome issues but can be an issue at any age due to genetics or other disorders or environmental or lifestyle factors (see below). Another option is that there are cycles for some people where a regular cycle of IVF with average to high doses are ‘frying the eggs’ or reducing the quality and some people choose to do a mini IVF or duo stimulation because it may take more rounds to get enough quality eggs and may require a lower dose of medication. An option that some women and couples choose is donor eggs or donor embryos, which requires a lengthy decision and a wonderful option for many people.
Sperm quality. Sperm is half the equation and sperm quality can result in issues that affect the quality of the embryo and, therefore, fail to implant. If you did IVF and didn’t do ICSI, then you may consider that if considering a future round. Just like egg quality, an option that some couples choose is donor sperm or donor embryos.
Sperm DNA fragmentation. Even if semen analysis results were normal, there could still be abnormal DNA fragmentation. The real test is the sperm DNA fragmentation assay, which looks closer at the sperm’s DNA. If choosing IVF, then IMSI instead of ICSI has been shown to be the better option if morphology is the cause.
Uterine lining was not thick enough. You probably wouldn’t have had your IUI or embryo transfer if your lining wasn’t thick enough. The benchmark for thickness depends on the clinic but it’s usually a minimum of 7mm to 8mm. You may need more medication such as estrogen for a future attempt and wait until you meet the threshold to transfer, otherwise you might choose to cancel the cycle or it may be cancelled for you.
Timing of transfer. Approximately 1 in 5 patients have this as one or all of the causes of failure to get pregnant through embryo transfer. A way to test is to conduct an ERA or EndomeTRIO tests. It’s a test in which a biopsy of the endometrium (up through your your cervix and into your uterus) is performed to see when your uterus is most receptive to implantation and if you need more or less meditation such as progesterone. For example, it might provide clues as to whether a future embryo transfer should be performed a day earlier or a day later than expected or it’s being done right on time. Your body can change over time, so if you did one and then another a few months or years later, the results could be different. !
Polyps, cysts or fibroids. Fibroids, cysts and/or polyps are often detected prior to transfer during routine testing, but if you haven’t had an HSG, hysterscopy, sonohystogram or transvaginal ultrasound they may be missed. The course of action and identifying if they are the issue depends on the type and location of these nuisances. For example, some cysts go away by the next cycle and some polyps grow outside the uterus and shouldn’t interfere with implantation while some fibroid or polyps are at a size that they do need removal no matter where they’re located. You’ll need further tests if your doctor thinks this is the culprit. If they need removing, depending what they are it’s often a surgery that can be done with local anesthesia in a fertility clinic or full sedation in a hospital setting. Rarely but it happens, cysts require more major surgery. There’s never a guarantee that they won’t come back – if they do, it’s because love your vaginal cavity so much! Aka, there’ not anything you’re doing wrong for them to crop up.
(Silent) Endometriosis. Otherwise known as endo, this disease affects about 10% of women in Canada and some individuals with endo don’t have any symptoms at all. The inflammation could be preventing transfer. If you don’t know if you have endo, an option could include seeing a Naturopath, having a diet for women with endometriosis that lowers inflammation, a surgical consult, or a Receptiva test and/or a pelvic exam to help diagnose. If there’s indication of endometriosis, your fertility doctor may suggest a process to suppress the endometriosis inflammation for a couple of months before transfer such as the flare protocol with a Lupron depot shot.
Adenoymosis. If you have adenoymysosis then it’s not uncommon to have endometriosis as well. Less is known about this decease and an MRI is usually needed to diagnose. Surgery may be required or a new protocol for transfer.
Hormone levels and/or inflammation. With inflammation it could be silent endometriosis (see above). Overall hormone levels that may effect implantation is harder to test. It’s something to consider seeing a Naturopath for if that aligns with your values. Looking at your overall health choices such as diet, exercise and sleep may be a good start. You could also consult a dietician to help you attempt the right changes for you such as a keto diet with less diary and complex carbohydrates and cutting out alcohol and caffeine. There are too many options to list here, but this might get you started.
Bacteria in the uterus. Endometrial infection can be a cause. A biopsy and the EMMA and/or ALICE test may be suggested and antibiotics may be administered as a treatment to heal and hopefully fully clear up the infection. Sometimes a vaginal suppository is prescribed whether this test is done or not to rule it out even without confirmation of the presence of the bacteria.
Thyroid dysfunction. Thyroid function may affect fertility. There are various types of thyroid issues and it is usually confirmed with one or more blood tests, including your thyroid stimulating hormone (TSH). An example is Hashimotos. Treatment will usually include oral medication and usually solves the problem but it might take a few months to sort out the right medication and dosage and your dosage needs can change. It can be frustrating to navigate and learning more about it can help.
Blood clotting issues. These are often inherited disorders such as thrombophilias and can usually help to know if you have a history blood clots yourself or you have a family history of it. Treatment may include medication such as blood thinners.
Technical issue. This means it was an error in the clinic, or in an ultrasound, and/or due to the fertility doctor or embryologist. This happens sometimes and there’s usually not a way of knowing or a way of preventing this. It’s a reality of human error that is inevitable for the very rare few who experience this and the even more rare few who are aware of it.
Lifestyle factors. It could be stopping smoking or using recreational drugs that are impacting your implantation success. Lifestyle changes such as cutting down alcohol and caffeine and supplements may help. Ensuring you’re not working where there are environmental toxins. If you’re exploring whether lifestyle factors are the cause for you, consider talking to your fertility doctor (and potentially a Naturopath) and dietician if you are concerned about your diet. It could also be due to sleep issues or not enough exercise or too much. Book a call with me if you want to discuss.
Immunological issues. It’s a bit of a jarring name, but it can be natural killer cells (NK) that are the cause or another immunology issue. There are tests but they are a bit controversial and not standard because it’s more rare. But if other causes are ruled out after usually multiple failed attempts, then testing can be conducted. You might have to advocate for them. Every clinic and doctor is different in terms of how willing they are to investigate this since it is more rare and can’t test every single patient, but it’s something to research. There are a few clinics in Canada and some in the United States that specialize in immunology or chromosomal issues. You could try and be referred to a reproductive immunologist or a physician with this specialty.
Anatomical issues. If you haven’t had any tests yet due to the stage of your IUI, then you might have an anatomical issues such as an unusually shaped uterus, vagina or fallopian tube(s) or damage to parts of your reproductive organs. Your doctor might have seen this as part of your next steps to get an HSG, and then if needed a hysterectscope and potentially an MRI.
Complications from a dilatation and curettage (D&C). The cause may be PID or scar tissue. Scarring would likely be checked through tests prior to the IUI or embryo transfer. The good news is often it’s reversible with a procedure.
Complications from previous childbirth. This may include PID or from c-section scarring or anatomical change. For scarring, it may be identified in tests but often a procedure can heal the scar enough to carry on having a baby
Pelvic inflammatory disease (PID). This could be due to sexually transmitted infections or more rarely, using an IUD and other causes. Usually this would have been ruled out before transfer. Medication can often clear it up before proceeding.
That’s it for now. This is not a complete list but gives you something to start with. I wish you so much luck and clarity with what to do next. You’ve got this and if it doesn’t feel like you do, feel free to book a call with me. I can coach you through it.
References:
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Ivanov P, Tsvyatkovska T, Konova E, Komsa-Penkova R. Inherited thrombophilia and IVF failure: the impact of coagulation disorders on implantation process. Am J Reprod Immunol. 2012 Sep;68(3):189-98. doi: 10.1111/j.1600-0897.2012.01156.x. Epub 2012 May 24. PMID: 22620672.
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Yamada H, et al. Pre-conceptional natural killer cell activity and percentage as predictors of biochemical pregnancy and spontaneous abortion with normal chromosome karyotype. Am J Reprod Immunol. 2003;50(4):351–4.