FET Next Steps - Advice Needed!

[Sunflower360]

Hi All

Sorry for the long message but hopefully some people can help with their own experiences!

I'm just in the tww following an FET of an untested 5AB, which is possibly looking like it failed, so I wanted to consider options as I was hoping to proceed with the next FET asap. Bit of background:

• Did 3 egg collections at 37/38 with low AMH and got 8 embryos (one of which has now been used and one is a day 3 as yet to be cultured, so 6 x blastocysts left)

• OH's sample has always been good but due to slightly lower morphology went for ICSI which has been good so far

• Had a Hysteroscopy to smooth lining, remove polyp (due to IVF meds), biposy taken/clear and cervix also widened as was too tight for FET procedure

• Last summer had a natural chemical pregnancy at 4+5, so implantation appears possible based on Drs view. Did miscarriage tests as proactive measure and found out I got thyroid antibodies so on low dose Prednisolone for any FET.

• Advised aspirin not needed as have good blood flow to uterus when scanned each time

• Did Natural FET this time with trigger and Cyclogest x 2. Last scan 2 days before my LH surge lining was 7mm

Any tips/advice on what to ask from my Drs review or what we could do differently next time (which I'm hoping we could do asap, maybe even this next cycle as Im on absolute minimal meds this time)?

Are there different FET protocols that could be considered? I'm not keen on the down reg option, plus I appear to ovulate, so is taking just a small dose of estrogen to thicken lining slightly more with the natural cycle an option?

Also is double transfer worth pushing for? My Dr is not keen on it at all for the first 2 transfers at least in case both embryos got lost due to the uterine environment, but with a chemical, now possible failed FET and being 38 is it worth asking again? On the surface my current protocol appeared to work well - lining looked like what they'd expect (not sure if it thickened past 7mm as I surged 2 days later, I think 8mm would be better perhaps), I ovulated, and transfer procedure went well so I can only think it was the embryo, not sure what else could be explored with the uterine environment?

Thanks in advance!

Most common reason for a failure is issues with embryos. I’d get them tested. Much better than having multiple heartbreaks.

@contentsmayb thank you for your reply. I have considered testing but am quite nervous about the thaw/test/freeze/thaw process (got advised chance is we'd lost at least 1 embryo in the process and with my low amh and age you never know it could be the 'good' one if there is one). Then also the results being abnormal/mosaics/inconclusive - it kind of still doesn't feel sure if that makes sense? And then you read that euploids can still lead to miscarriage and not work so kind of negates having the test done. I don't mind putting them back in and giving them each a shot but just wanted to ensure all else has been explored/ruled out etc when putting them in. If its the embryo then so be it and it really is trial and error, not much I can do about that as I'm getting older 😬

Hi OP - how many days past transfer are you? Did they transfer the best graded one? Hang in there.

I'm also preparing for a FET, thought it would be early April but period came early so looking like last week of March (if the ERA results comes back in time). I'm interested to know how soon can you do another if this one fails..

I haven't tested my embryos too, I tested 4 previously and only 1 came back normal and that didn't implant. So I want to give them all a chance this time (instead of risking having them discarded inaccurately..).

My clinic is in Prague and I've asked about double transfer. They said it's possible looking at my notes, but generally not encouraged because of (1) the possibility of twins (which I personally think would be a blessing!) and (2) the risk to the woman carrying the twins... My rationale is though, because I haven't tested them, a double might give me a better chance i.e., hoping there is a normal one that will hopefully implant. I have an older friend who did a double and lost one (daughter is in her 20s now!); she said the other one just bled out... not sure if it ever implanted.

@Sunflower360 so sorry for your loss and struggle.

IVF is a treatment where efficiency is low, which means most couples will face failure more than they will have success. So it could just be that for you (and me too).

I agree with you that testing embryos after they have been frozen is not a good idea. And testing is not foolproof either, you run the risk of discarding an embryo that could self- correct once in the womb. But it's an option if you ever have to go through egg collection again (hopefully not).

If you have already done the tests for miscarriage, I am not sure there is anything else you can do additionally.

My fresh transfer using DE failed and I am about to start FET. Previously three own egg cycles were unsuccessful. Like you I also wanted to do tests for the uterine environment and do things differently.

But my doctor advised against doing any add-on tests saying there is no evidence to back these up and it's too early to investigate implantation issues. He only suggested Hysteroscopy as a tiny polyp was suspected. It has been removed since then. I'm also doing Natural modified cycle for the first time.

As mine is a DE cycle, he also suggested we stick to one embryo. But I think you can definitely look into a double transfer given your age and own egg cycles.

My advice to you is do not hold back. Ask whatever questions you have, regardless of how small or silly they might appear. You have to feel positive and confident when you start the next FET. It's only possible when you are satisfied with the answers for all your questions.

Six is a great number of blastocysts, so hopefully one will stick and soon 🍀

@blahblahetc According to my clinic, you can do back to back FETs if you feel up for it as there is no ovarian stimulation involved, so recovery time not required.

@blahblahetc I'm 6dp5dt with a 5AB embryo (I have others frozen that are 5BA, 5BB x 2, 5BC, 5CB and 4CC -so a mixed bag really. I did a cheapie
test yesterday morning at 5dp5dt but it was a definite negative at that point (I tested as I felt quite hot/breathing rate increased/nauseas the evening before at 4dp5dt) but that has now all gone and its fair to say I'm back to no symptoms (I did feel quite bloated/pulling/heavy womb feeling in the first couple of days after transfer but that's all stopped too). As I've had no more symptoms I've not tested again but will ride it out until OTD next week, got my Dr follow up the same day as I want to get a plan together asap.

Thanks for your advice. Twins would be great, but right now I'd be grateful for just one and the way things are going twins may be a pipe dream! I was kind of hoping putting two in in the hope one sticks at least- saves time more than anything then if we wanted to consider another EC we could do so before my AMH decreases further and as I'm getting older. Are you planning on doing a double transfer? Also what is you FET protocol in terms of meds etc?

@Serendipity24 thank you for your reply. It is quite a relentless road, and knowing what to do for the best is the hardest part. Good to know back to back FET could be n option, I do want to get through them rather than have unnecessary breaks. Double transfer I'll speak to the Dr about as he really wasn't keen on it all when I last spoke to him but after this round perhaps he may advise otherwise. What FET protocol are you doing?

6dp is still early :) Give it another day or 3 at the very least; or wait till OTD if you have the patience.

I know the chances of my body holding twins is near nil.. and given the stats re. euploids (I was told 1 in 4 by my previous clinic), if I could I would transfer 4! That will save time, money and energy/sick leave if miscarrying..

I am planning to transfer 2, just pending confirmation from my doctor. He already gave the green light last time.. I'm quite medicated: 3 x 2mg estrogen, 1 x prednisolone and 1 x 100mg aspirin currently.

Thanks @Serendipity24 - Good to know so I can make a plan B!

@Sunflower360 I am doing natural modified with Ovitrelle trigger and progesterone only.

And I agree with @blahblahetc that it's too early to feel negative about the current transfer. A lot of people do not have any symptoms or have fleeting symptoms. 🍀

@blahblahetc It is little earlier for me to completely say it hasn't worked, but sometimes its just a gut feeling, will know for sure soon enough! The 3 x estrogen when did you take that from and is that to thicken lining and how long is that for? So you didn't have to down reg, is a follicle still measured and your natural Progesterone plays a part too?

@serendipity sounds like the same protocol I was on, I kind of want to stay on something similar if I can to minimise the need of meds if possible but will see

I started on the meds day 2 of my period, and will continue to take them until told (the nurse said I will mostly likely continue taking them until week 12 if successful). I will swap the aspirin for 40mg clexane after transfer - just more economical that way. Estrogen for lining, aspirin/clexane to encourage blood flow and prednisolone for NK cells.

I have to get a scan done on day 12, and based on that (+ ERA results) they will tell me when to start on progesterone pessaries. I also need to have a progesterone blood test on day 12 to determine if I need progesterone injections (instead).

@blahblahetc ok that makes sense. Do they still base transfer on when you surge or does that not happen? Was Prostap involved?

I'm not too sure really, my understanding is the ERA will determine the implantation window, and they will then manipulate the progesterone timing/dose to optimise uterine receptivity.. I have done 1 FET previously (June 2023) and started on progesterone on day 8 of period cycle.. so this is done very differently. No prostap mentioned for both.

@blahblahetc thanks

I've been thinking, if my chemical last year was due to an aneuploid/chromosomally abnormal embryo and this embryo from this FET was also aneuploid but has not implanted at all shouldn't this have also been a chemical? Why would one end up in a chemical/implant but then the another does nothing? If that makes sense at all what I'm getting at, trying to make some sense of it! In any case I'm sure this has failed and is a BFN, did a FRER and its a definite negative, I'm 7dp5dt so it would have shown by now as the detection on the FRERs are so low.

@Sunflower360 sorry that your test is still negative. However, my clinic last time advised against home testing that early. My OTD was on 8dp5dt and they said I should only do a blood test and wait for another 2 days at least for home pregnancy test. Have your clinic asked you to do a blood test?

In terms of implanting or not, nobody knows why some embryos implant and others don't. Sometimes aneuploid embryos implant and doesn't progress while sometimes no pregnancy is achieved even with an euploid embryo. It is frustrating to say the least.

@Serendipity24 OTD is Weds, my period was due on Monday based on my ovulation date, but appreciate that is unlikely to start until I stop Progesterone which I'll carry on until OTD - suppose its a good thing the pessaries are doing what they should as I normally would be spotting today before my period on Monday. No hcg blood test, just urine, but I'm comfortable with that for now as the FRERs are accurate. If I was to get a positive in the future I would push for a blood test moreso to monitor levels.

It is crazy though, has no logic really why some implant and others don't. Be interested to hear the Drs views as I'm not really sure if further testing on uterine environment etc is validated seen as I've had quite a few investigatory tests/remedies in place already. It may be just trying another embryo and see what happens although I think I'd like to see my lining thicker I think as in the last scan it was 7.1mm 2 days before I surged (not sure if it increased further after than scan). I'm also wondering if the Prednisolone is sufficient for my thyroid antibodies or whether something else on top may be beneficial like IVIG but I don't know a lot about that in all honesty, my last TSH appeared normal (under 2) in January but I'm going to get that tested again before the next transfer as I'm monitoring it via my GP.