IVF and immune screening

Dear Professor Winston

I have found this website enormously helpful over the last few months. It has certainly made me think carefully about the statistical probability of me getting pregnant via IVF, despite the claims of various clinics. My question is related to immune testing. I am 37 and my HSG test showed that one of my tubes is blocked, the other partially blocked. I have had a couple of abdominal surgeries due to Crohns Disease that I suspect may have created scar tissue, causing this blockage. Aside from that I am otherwise healthy. I have a low AMH of 8. My first IVF cycle resulted in a chemical pregnancy (2 eggs retrieved, 1 x 5 day blastocyst transferred). My second IVF cycle failed (4 eggs retrieved, 2 x 5 day blastocysts transferred). My husband is 39 and has no issues. We’d like to embark on another round of IVF treatment, which we will have to pay for. Our clinic is an NHS hospital in London, and they don’t offer immune testing as part of the regular IVF treatment. Given that I may have implantation problems, I’ve been reading about the raft of immune tests offered by other clinics – including the Chicago tests, thyroid screening, antibody screening, infection screening etc. All of these tests claim to be useful for women with implantation problems. I’ve read your thoughts on NK cells – what do you think about immunity screening in general? Our current NHS clinic is a major London research hospital. My head is telling me there’s a reason they don’t offer this service (ie, there is no medically proven basis for these tests), but my heart is telling me that I’m desperate for the next cycle to work and I want to do anything possible to improve my implantation situation. Thank you in advance, R.

Dear R,

Sounds to me like you are going to an honest clinic.

And it doesn’t sound to me that you have any real evidence for a major implantation problem, particularly one that would be moderated by these ’remedies’, ‘chicago tests’, thyroid screening, antibody screening, infection screening etc. Let me repeat – I know of no randomised control trials which demonstrate the slightest advantage in these treatments or these ‘screenings’ to IVF patients. One possible exception could just be thyroid screening, which is cheap and can be done under the NHS, and in very exceptional cases, infection screening. Though, I must emphasise that very few symptomless infections indeed prevent implantation of the embryo. Please note the name ‘Chicago Tests’ a city which, (you can check on the web) it is not unusual for a single cycle to cost $17500 (around £10,500), and according to one Clinic website $30,000 for a single treatment cycle. Such clinics probably do not need independent scientific proof of the efficacy of their treatment, merely enough fear from patients to try any new procedure which ‘may’ help.

If you have an implantation problem at all, it could well be due to your previous Crohn’s disease, which does occasionally affect the uterine wall and sometimes this damage can be seen on HSG if assessed really carefully. But you are responding quite poorly to superovulation which could be a feature of age or your lowish AMH (you don’t tell me what units were used for measurement). Your Crohn’s has also caused adhesions, presumably scar tissue around the ovaries, and I suspect you have possibly had some inflammation (salpingo-oophoritis) around your tubes and ovaries. In my experience this a feature of this disease and could easily explain the rather poor response to gonadotrophins. And of course, a poor response might yield ‘less good’ eggs, though admittedly you got two blastocysts from your second cycle.

Overall, the pregnancy rate for a given cycle is 25% and about 33% for blastocysts transfer – I don’t have enough figures to know what the rate is for two blastocysts – I do not think the controlled trial has ever been done. But overall, even with reasonable embryos, you possibly have had, at best, only just over a 50-60% chance of conception and many horse-racing enthusiasts there have lost money on a 3-2 odds on bet. I think I would continue as you are, but know that your implantation rate may well be a bit lower than average, as it tends to be in women with burnt out Crohn’s disease.

Very best wishes
Robert Winston