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Fertile Thoughts:...

Fertile Thoughts: Cynical and Broke

Q: How many times should a couple reasonably try in vitro before giving up? My husband and I have had eight failed attempts, as well as five failed frozen embryo transfers. We got pregnant once, which ended in miscarriage at seven weeks. Our specialist is confident we will eventually get pregnant, but I am cynical and broke.

A: Most pregnancies that are going to occur do so within three cycles of treatment with any treatment regimen and that includes in vitro. Additional cycles may be justified if new information is discovered during the process of treatment that allows changes to the treatment plan to hopefully improve the outcome. Presuming that you are a healthy woman with a normal uterus, outcomes from in vitro are dependent on a number of factors including principally your age, the number and quality of eggs and embryos you produce, the ease of embryo transfer, and to a lesser extent, the quality of your husband’s sperm.

From what you have said in your question, it seems that you stimulate well enough to produce a reasonable number of eggs and embryos (you get eggs that fertilize normally; enough embryos are produced to allow for fresh embryo transfer and extra embryos to freeze). These are all good things.

There are some additional things you need to address to improve your outcome (perhaps they have already been addressed and you didn’t mention them in your question). Was there any difficulty with your embryo transfers? The pregnancy rates from in vitro relate directly to the ease of transfer. Have you had a recent sonohysterogram and trial sounding with the embryo transfer catheter? We repeat these tests yearly in our in vitro patients. The development of a polyp or fibroid growing into the uterine cavity can adversely affect your chances of becoming pregnant. Did you have a D&C with tissue sent for genetic testing when you had your miscarriage? It is important to know why you miscarried. Most people miscarry because the pregnancy itself isn’t normal and the miscarriage is nature’s way of taking care of that. If the products of conception can be obtained and sent for genetic testing when a woman miscarries, more than half the time a chromosomal abnormality is found in the pregnancy.

Embryos can be tested for many of the most common chromosomal abnormalities that are seen in miscarriages before they are transferred into a woman’s uterus. The testing of embryos prior to transfer is called PGD (preimplantation genetic diagnosis). This testing has been shown to reduce the risk of miscarriage. Women who have difficulty becoming pregnant at in vitro, and who miscarry when they do become pregnant, may produce a high percentage of abnormal embryos (sometimes as many as seventy-to-eighty percent abnormal). You cannot always tell which are the normal vs. abnormal embryos when you look at them. Sometimes the most perfect looking embryos are abnormal. For some women, PGD can allow the doctor to choose the best embryos for transfer into the woman’s uterus and therefore optimize her outcome. I hope PGD has been used in at least some of your in vitro cycles. Then you would know what proportion of the embryos you produce are normal. That information can help you to decide whether it is worth considering additional in vitro cycles using your own eggs or if you would be better served to consider using donor eggs from younger woman (pregnancy rates with donor eggs can be as high as seventy-to-eighty percent).

Read the May Fertile Thoughts Column

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