After unsuccessful attempts in IVF treatment, the chance may gradually decrease in repeated treatments. Therefore, before starting a new treatment cycle, all factors that may cause failure should be investigated in detail:
✓ All abnormalities that may prevent the adherence of the embryo to the womb such as intrauterine adhesions, fibroids or polyps should be corrected by hysteroscopy method.
✓ When fallopian tube is occluded, a fluid accumulates inside the tubes and this fluid prevents embryos from adhering to the womb. This condition, called hydrosalpinx, is diagnosed with ultrasonography or uterine film (HSG-hysterosalpingography). This fluid flowing into the uterine cavity and preventing the embryos from adhering is treated by closing the part of the tubes close to the uterus by laparoscopy method or surgically removing the tubes.
✓ The other factors that prevent embryo development and attachment to the uterus are hormonal disorders such as thyroid gland diseases, increase in milk hormone (prolactin) secreted from the pituitary gland in the brain. These should be investigated and treated with drugs before starting IVF treatment.
✓ Polycystic ovarian disease (PCOS) and the increase in insulin hormone may cause difficulty to conceive and may lead to miscarriages. For this reason, the chance of getting pregnancy can be increased by administering diabetes drugs that reduce insulin resistance. Losing weight would be of great benefit.
✓ Congenital or acquired problems related to the immune and coagulation system should be investigated by performing advanced blood tests and their treatment should be provided with the use of appropriate drugs when needed.
✓ Detailed sperm analysis should be done. Genetic tests (such as chromosome analysis, Y chromosome microdeletion test, sperm FISH test) and hormone tests should be performed if there is a severe decrease in the number, motility, (Asthenozoospermia-reduced sperm motility and Oligozoospermia-low spermatozoon count or both low sperm count and low motility- Oligoasthenospermia) or a high pertentage of abnormal morphology in the sperm which we name as Oligoasthenozoospermia, also in man with no sperm in his semen (azoospermia).
Previous studies for different populations have shown that the incidence of chromosomal abnormality in infertile males varies between 2.2% and 19.6%. The most common chromosomal abnormality in these studies was Klinefelter’s syndrome followed by Y chromosome microdeletions. In recent studies a 7.1-10,3% of major chromosomal abnormalities was reported in infertile males, of which 21% were azoospermic. These studies pointed out that the frequency of chromosomal abnormalities were high in patients with abnormal spermatozoa. Further, in azoospermic patients more than 90% of abnormalities affect sex chromosomes while autosomal chromosomal abnormalities are more frequent in patients with oligozoospermia.
If a chromosomal abnormality or Y chromosome micro-deletions is detected in man, PGT (Preimplantation Genetic Testing) technique should be used in an IVF treatment trial to select the healthy embryos.
✓ In patients with endometriosis IVF is appropriate treatment, especially if tubal function is compromised, if there is also male factor infertility, and/or other treatments have failed.
The effect of endometriosis on IVF pregnancy success rates are contradictory. Some research studies indicates report low IVF pregnancy rates in women with endometriosis are about one-third lower than those of women whose infertility is a result of tubal damage. On the other hand, most of the large databases of women with IVF treatment shown no differences in pregnancy rates.
Endometrioma or endometrioid cyst, is a type of cyst formed when endometrial tissue grows in the ovaries. These cysts are benign and estrogen-dependent.
In patients with large endometrioma there is also a debate about laparoscopic excision with no treatment before IVF. Most studies advice laparoscopic ovarian cystectomy if an ovarian endometriomas ≥ 4 cm in diameter. The advantages of endometrioma excision are: confirming the diagnosis histologically, reducing the risk of infection, improving the access to follicles, and possibly improving ovarian response and prevent endometriosis progression.
On the other hand in some studies it is shown that leaving an ovarian endometrioma in place does not seem to affect the success of IVF treatment and does not affect the resulting pregnancy rates. However, surgery to remove the endometrioma may result in fewer eggs being obtained as some of the adjacent ovarian tissue, including some follicles (potential eggs) also removed during surgery.
Therefore, the woman with endometrioma should be counselled regarding the risks of reduced ovarian function after surgery and the loss of the ovarian reserve.
Adenomyosis is a benign disorder where heterotopic endometrial glands are found in the myometrial tissue of the womb. 1% of female patients, more often made in multiparous patients, in their fourth and fifth decade of life have adenomyosis. Prevalence of adenomyosis in subfertile patients may be increasing since more women delay their first pregnancy until later in their thirties or forties.
The presence of ultrasound diagnosed adenomyosis was associated with a significant reduction in successful implantation of good quality embryos in patients undergoing GnRH antagonist stimulation for IVF treatment.
Indications for surgery were based on size and extent of lesions.
No systematic study of any medical regimen aimed at treating infertility associated with adenomyosis has ever been attempted, although a variety of drugs have been employed over the last 20 years The first agents utilized for this purpose were gonadotrophin-releasing hormone agonists (GnRHa)) and several case reports or small series have been published of successful treatment of adenomyosis-associated infertility with GnRHa, given alone or in combination with surgery.