Shell thank you for your kindness - you must be nearly about ready to pop now?
You pose some interesting questions, have done my best to answer them - although until I’ve seen the Dr and had a more detailed discussion, will have a more solid plan of action!
Genetic testing
With regard to PGS, the old style technique did only used to look at a selection of chromosomes - new CGH testing now looks at the full set of chromosomes and is significantly more accurate. It not only identifies trisomies and other major chromosomal abnormalities, but ‘smaller’ defects such as micro deletions and duplications.
Now, it is not foolproof, particular as regards mosaicism, but it is certainly far far more accurate than embryo morphology
Anecdotally, the three ladies I know who had PGS found that their morphologically ‘top quality’ embryos were aneuploid, and that their supposedly poorest quality BC embryos were actually genetically perfect.
Similarly, it is interesting to note how many women have failed transfers of AA blasts and then success with their lower graded blasts
Certainly the statistics for clinical pregnancy and live birth rates with PGS at the clinic whose lab my consultant uses for IVF, are overwhelmingly higher than the non-PGS cycles
When it comes to the cytogenetic of products of conception, as I understand it, it very much depends on the quality of the tissue obtained as to the level of information the tests will be able to supply. As with PGS, the newer technologies are more able to discriminate between maternal and fetal tissue than the older karyotyping methods - once maternal cell contamination is reduced, the rate of false negative results drops. So yes, it is absolutely possible that if the testing shows the foetus was chromosomally normal, this could indeed be a false negative - however it is certainly the most accurate method of testing we have, and significantly more accurate than it used to be
Immunes
As regards immunes, I will be interested to discuss this further with my consultant. I have already had all the level 1 immunes tests (incl thrombophilia) which all came back negative, however I haven’t had the level 2 immunes tests. My Dr said that he doesn’t find the Chicago tests particularly reliable, as NK cells levels in peripheral blood testing aren’t necessarily an accurate indication of what’s going on in the uterine environment. He prefers to treat empirically, as he doesn't use Humira or IVIG, but uses the much more benign immunes therapies.
Treating empirically doesn’t just mean ‘we’ll chuck the drugs at it just in case’, but does mean making the decision to prescribe basic immunes tx on existing indications
For me, the areas that suggest there may be reason to think some level of immune response may be worth treating include:
- TSH at the upper end (within normal range, but higher than many clinics would like for fertility)
- high CRP levels suggesting possible inflammation
- feeling cold/flu like symptoms in the days following transfer
Professors Quenby and Brosens do indeed argue that prednisolone may do more harm than good in women with very low levels of inflammation, as some inflammation is needed (hence the benefit of the endometrial scratch). However this is quite unusual, and especially where there are other markers for inflammatory response, prednisolone and intralipids are very low risk and can be hugely beneficial.
So, we will see what our conversation elicits, but as there is limited evidence of any deleterious impact of steroids + intralipids, and in the presence of soft indicators of a possible inflammatory response, I would feel confident that adding immunes tx to my next transfer cycle would be the sensible thing to do.