January 24, 2018

Difficult embryo transfer

I received this comment this morning for a previous post.

Thank you for this very informative article. I am 30 years old and am having my first FET this October. I did not get to have a fresh ET because of OHSS-IVF resulted in a freeze all cycle. I have 5 perfect frozen blastocyst. A little history on me, I have had 5 failed IUI’s…not sure if the sperm could not pentrate the eggs because all my eggs were fertilized with ICSI. For all the IUI’s I had a different RE do the procedure (same clinic difference RE’s) I think they work in a rotating schedule. I was never told however, I think my cervix is tipped to the left because each RE had trouble getting the catheter through my cervix (one RE used a clamp-very painful). I did have a trial transfer for the IVF and my assigned RE did again have trouble and had to use a second catheter. I am now not sure which RE will do my FET ET, I am afraid I will not get a BFP because they will have the same problem again. As a medical professional, would you be offended I point this out to my RE and nurse? I am sure they make notes, but I feel like I need to be my own advocate. Thank you!

Linda

Dear Linda,

Being your own advocate is a great thing to do, because who else is going to be as invested as you in your own care? It’s so coincidental that you left this comment today, because last night, I attended our bimonthly Orange County Reproductive Endocrinology Journal Club. This is something I organized where local RE’s, embryologists, infertility nurses, acupuncturists and other interested healthcare professionals get together over dinner to discuss topics. And guess what the two topics were? Well, I facilitated a discussion of embryo transfer technique and another RE facilitated a talk on Assisted Hatching. I’m not sure if I’ll ever get around to writing a post on the details of our discussion, but we did talk for an hour just on the topic of embryo transfer. Each of us RE’s apparently do things a little differently with respect to catheter used, when and how we do our mock transfer and of special interest to you, how we manage our difficult transfers.

Single Tooth Tenaculum

I’m guessing that your doctors are very experienced and have had many successes, so they probably each have their own personal routine that has worked well for them. Having said that, I’ll share that most RE’s believe that placing a tenaculum (clamp) on the cervix is associated with lower pregnancy rates. There are a couple possible explanations for this. Clamps tend to be needed only on patients with a difficult transfer, so the lower rates could be just due to the difficult cervix and not due to the clamp. However, if it came down to a choice on the type of clamp, there are some last night who advocated an Allis clamp, rather than a tenaculum. Why? The tenaculum is like two spiked pincers whereas the Allis is more spread out and has tiny short teeth rather than long spikes. Frankly, I don’t use either. If I know ahead of time that there is a tough transfer coming up that would benefit by my being able to apply gentle traction to straighten out the cervix, then I place a single suture on the cervix at the time of the egg retrieval while the patient is still comfortably asleep. For a FET, since there is no retrieval, I bring the patient back 1-2 days before the transfer under local anesthesia. This has the benefit of not causing trauma nor pain to the cervix on the actual day of the transfer. A cervix that gets pinched or clamped often gets angry and transmits that anger to the uterus which may then protest and spit out the embryos via forceful contractions.

Allis Clamp

Allis Clamp

Last night, one of the doctors swore that he witnessed that happen as he saw the droplet on an ultrasound-guided transfer get squeezed out of the uterus before his very eyes.

The bigger issue for you is not so much the specifics of your transfer, because I certainly don’t know your uterus and cervix as well as your doctor does. Also, this is just the way that I personally do it. It’s not the only way and not necessarily the best way. The issue would be your ability to forge a relationship with your RE so that they address your concerns to your satisfaction. Also make sure it’s their ACTIONS that you respond to and not just their WORDS. Sometimes, doctors will listen to your concern and say, “OK I will make sure I do everything in my power to ensure your transfer goes smoothly. But then when the time comes, they forget or as in your case, they might not even be there. This is where you have the power (in a free market) to exercise your power as a patient and take your business elsewhere if you’re not satisfied. I realize that I may have not given you a very satisfactory answer because you might not be in a free market situation, meaning you might have your choice of doctor limited because your insurance is paying. However, if you’re paying out of pocket for your treatment, that that’s better in the sense that you can pick and choose where to go and this always leads to doctors being more attentive and more accountable to their patients. Good luck. I hope you get a healthy baby or two.

  • Jennifer

    Dear Dr. Lee,
    This reader’s question stirred some indepth thoughts for me, and I’m very curious about your opinion.

    I have been dealing with infertility for a few years now. I’ve done 5 IUI’s, moved on to IVF since I over responded to the 6 IUI with 12 eggs and the RE suggested that I didn’t want to turn out like Kate Plus Eight. 😉 I suffered OHSS from my first IVF and we froze 4 blastocysts. I did a second IVF the very next month. I only produced 2 blastocysts and both were fresh tranfers 5 days later. I did, however, end up in the hospital with a severe case of the flu the next day and had a BFN the next week. I then did a FET and transferred two of the thawed blastocysts. (Just before the FET they did a Thrombophilia panel and discovered MTHFR-2 homo. gene mutations) put me on Arixtra blood thinner and folic acid. The FET was a success- a singleton. I delivered her stillborn at week 20, day 5. There were many theories from my doctor, but my RE believed it was because they took me off of the blood thinner after the first trimester. I did a second, and final, FET and transferred the last 2 frozen embryos in May. I am now 22 weeks pregnant with another girl. I did, however, have to have an emergency cerclage put in at week 18 due my cervical length being less than 2 cm and I was 70% funneled. I’m now on bedrest for the remainder of the pregnancy. (I’m 40. They’re being extra cautious).

    My point in all of this is to share with you that my Perinatologist and Obgyn are very skeptical of the blood thinner. They do not believe there is a need for anything more than folic acid to treat the MTHFR. They say my homosisteine levels are normal. However, this second pregnancy I am seeing a hematologist who studies MTHFR at Emory, Dr. Alexander Duncan. He is advocating for me to stay on the blood thinner the entire pregnancy. What are your feelings on the use of blood thinner? Why do ob’s seem to shun it’s neccesity?

    One final question… My ob believes that I also had an incompetent cervix in the first pregnancy that was not caught. He does not believe the removal of the blood thinner treatment to be the cause (as my RE does). I agree with him because I was having contractions weeks before the loss and tried to explain that in several phone calls to the high risk ob. Either way, the ob and high risk ob (Perinatologist) say that IVF patients tend to suffer with IC (incompetent cervix) because of the many treatments and the damage done to the cervix during the treatments. I have found little information on that issue on line. I’m curious about your thoughts on that. I’m also curious to know if RE’s around the country might be gathering data in regards to IC in IVF patients resulting in stillbirths. I think it would be worth paying attention to. It could save future lives. Don’t get me wrong. I’m not bitter. I’m just thankful to be pregnant again and that they caught the IC this time. I jus wonder if my ob is right- that IVF patients suffer cervical damage in all of their treatments and it compromises the competence of the cervix.

    Thanks for you input,
    Jennifer

  • IVF-MD

    I don’t believe that IVF or IUI’s damage the cervix at all. Also, part of the definition of true incompetent cervix is painless (no contraction) dilatation.

    As for the topic of giving heparin to someone with MTHFR mutation, but normal homocysteine, I would potentially give different advice to someone who has a first-time pregnancy vs someone who has already suffered a tragic loss. Best of luck.

  • Linda

    Doctor,
    Hi. I just wanted to update you and thank you for your advice. For my egg transfer my RE did not need to use a clamp. The RE used a different catheter called a Introducer and the procedure went smoothly.

  • IVF-MD

    I like using an introducer to navigate an outer sheath past the difficult areas. Then you are guaranteed to be able to take the soft delicate part and get it to the destination without fail. It’s a little extra work, but in a patient with a difficult cervix, it’s well worth it! Best of luck to you. I hope you get pregnant this time.

  • EmilyChristopher

    Embryo transfer is the most important step of IVF process since its success depends on this final step. Embryos are usually transferred to the uterus of woman at 2-8 cell stage. Before this step, doctors should ensure the quality of embryos, which can be done through a device embryoscope http://www.emolinks.com/story.php?title=ivf-embryoscope-time-lapse-system whose details are present here. It provides time-lapse video of each embryo to best one for transfer. Embryos might be implanted anytime between first to sixth days after the egg’s retrieval.