In case you are in this situation, that is the absence of pregnancy after 2 embryo transfers of 2 good quality embryos, both when fresh or frozen embryo transfers, in this case, you would require a special treatment to improve the endometrial implantation as well as a better selection of the embryo to transfer.
Because the causes of the implantation failures may be many (age, social habits, hormonal, immunological, anatomical, genetic, estrogens…) you may need several multiple actions. Besides the recommendation to carry out, in any of these cases, previous hysteroscopies and endo-cervix cultures to discard anatomic problems or inflammatory factors, we would need to carry out several actions in order to improve the implantation. These are:
1. Embryo selection: May be this point, in our opinion, is one of the most important to achieve the desired pregnancy. This situation may be solved by the following techniques:
1.1. Time Lapse (Embryoscope). The use of this technology will allow a better selection of the embryos regarding the kinetic parameters (of development) of the embryo during the culture in the incubator. And likewise, with this technology, the embryo is developing in the same culture medium without the need of taking it out of it to check. With this, we will achieve a better selection and culture.
1.2. PGD Array CGH. This system analyses all 24 chromosomes of an embryo in less than 12 hours and transfers only those that are not affected with any chromosomal abnormality (in the last studies it has been proved that, in patients with good prognosis being 32 years old, the genetic abnormality rate in their embryos was 45%). With this technique we will increase the implantation rate to 75% on the 1st cycle and we will also decrease the miscarriages from 26% to 8-10%.
In case of difficult embryo transfers, because of an altered-stenotic cervix, or patients over stressed or nervous, we will practice a soft sedation for their convenience.
Thrombofilia studies, since there are studies that support the presence of coagulation alterations in those patients with implantation failures.
3. To discard the presence of endometriosis.
4. To achieve a good endometrial lining some vaginal ultrasound scan should be carried out in order to improve the doses of estrogens (oral or vaginal), to prescribe vasodilators (sildenafilo, pentoxifilina) and stimulating factors of colonies of granulocytes.
5. To improve the immunology to make the embryo implantation possible. In this case we would use:
5.1. Treatments with Intralipids, that reduce the immune response
5.3. Treatments with intravenous immunoglobulin
6. To use anticoagulants: administration of subcutaneous heparin, sometimes associated with acetylsalicylic acid.
7. In case of endometriosis, to previously administer analogs of LH during the treatment.
8. In case of hidrosapinx, to propose removal or tubal occlusion.
9. To improve the endometrial stimulation with scratch previous to the embryo transfer and prescribe growth hormone.
10. In case that the male partner presents sperm abnormalities, we would carry out a sperm selection previous to the fertilisation with MACS technique (anexine columns). With this technique, we can eliminate the apoptotic sperm (the unsuitable ones), to carry out a good fertilisation.
11. Likewise, in our egg donation and failure implantation program, generally we will carry out transfers of embryos in Blastocyst stage to improve the implantation and a better selection and endometrial synchronisation.
12. In case of frozen embryo transfer on those women of an advanced age (more than 40 years old), we will carry out assisted hatching.