Physician-To-Physician Consult

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?

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

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Answer by Manish Banker


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.

Dr. Manish Banker

Answer by Pedro N. Barri

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

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

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