Question of the Day: Failed FETs, what to do next?

Question of the Day:

Hello Dr,
I had egg retrieval in sept 2011 5 blastocyst and 6 third day embryo.I ended having OHSS and transfer was cancelled. I had my FET done with one five day embryo in october 2011 which did not work.
I had one more FET done with two embryos from third day. Today is 12th day and I got -ve on HPT.I also gave my blood this morning will have results tomorrow.I am afraid that result may be -ve.
At this I do not know what to do for IVF to work.I have followed all the instructions religiously.

What would you suggest if I was your patient. Or what you do different in my next FET cycle.

DrG answers:

Clearly a very frustrating situation. Here a patient had a great response to IVF medications…so great that she had to freeze all the embryos. The embryo development sounds pretty good as 5 blastocysts and 6 D3 cleavage stage embryos were frozen. Following 2 FET attempts nothing has worked.

However, I don't have all the details. Why were there both D3 and D5 embryos frozen? Why did the second FET involve the transfer of D3 embryos instead of D5 embryos?  How experienced is the clinic with D5 freezing?

A few years ago we changed to ultra rapid freezing or vitrification of our blastocysts. Slow freezing is not as good an option when dealing with more developed embryos. We usually see a 95% survival rate with D5 embryos and the implantation rates are identical for fresh vs. frozen embryos. However, not all clinics have as good a track record so these questions needs to be asked in order to better understand why there has been no success in spite of the cryo-all…

However, let's assume that this is my patient and I have a great confidence in my FET program. I think that if the actual embryo transfers have been easy then one has to consider there may be a uterine factor. Patients in this situation may benefit from a hysteroscopy and an endometrial biopsy to further investigate the failure to initiate a pregnancy. Interestingly, performing an endometrial biopsy may improve implantation in the following FET cycles. The mechanism of action may involve reparative changes in the lining following the biopsy but no one really knows…. Finally, I assume that assisted hatching (AH) has been used in the prior FETs but if not then clearly AH should be used...

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