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A difficult case of implantation failure

Dear colleagues

I'm treating a nice couple, she has 34 y'old and they had 8 embryos transferred(4 in D3, 4 in D5 blastocysts), without any implantation. ERA shows a receptive endometrium (natural cycle). The lastest 2 FET was with a minimal stimulation with Menopur 75UI every 2 days cause she had thin endometrium after the test, with natural cycle (even after sildenafil etc).
With Menopur, she responded with a good endometrium and I triggered with hCG and started progesterone vaginally on LH+3, but again, no prenancy.
She has only an elevated anti-beta 2 glycoprotein IgG and had heparin and ASA in all FET. Now she did a hysteroscopy (normal) but the biopsy showed a polypoid endometrium with proliferative activity and ciliated and tubal metaplasia, without atypia. What would you do?

Thanks
Renato Tomioka, M.D.  University of São Paulo, Brazil

View Answers

Answer by Manish Banker

Hello,

1. If the ERA is performed in a natural cycle, the subsequent ET has to be carried out in a natural cycle; any drug administered changes the endometrial gene expression. If the endometrium developed well in the natural ERA cycle, it should develop well again. Alternatively, ERA should be repeated in a HRT cycle on P+5 day.

2. At the age of 34 years, I would also be temped to offer PGS.

Regards,
Dr. Manish Banker

Answer by Pedro N. Barri

Hello,
I think that it would be interesting to repeat a new attempt under GnRH antagonists+ rec FSH+ hMG. You can also evaluate the possibility of PGS and deferred embryo transfer with previous evaluation of couple's karyotypes.

Dr. Pedro N. Barri

Answer by Michael Alper

Hello,
I would consider Pre-implantation Genetic Diagnosis (PGS) on embryos (blastocysts). Freeze all embryos and transfer euploid embryo(s) in natural cycle.
Best
Michael

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