A lot of women have trouble becoming pregnant, whether or not they have Endometriosis. The question has been raised : if you have Endometriosis and are undergoing frozen embryo transfer (FET), which treatment regimens and protocols have the highest successful pregnancy rate?
I myself have never considered IVF and had to do a bit of initial research on the differences between fresh and frozen embryos, IVF, etc. I am so grateful an EndoSister asked this question; brought this struggle to my attention. So if you already know about these, please bear with me as I learn. Otherwise, skip passed these first few categories to the knitty gritty below 🙂
In vitro fertilization (IVF)
IVF is when eggs are collected from a woman’s ovaries, and are introduced to sperm in a laboratory (called insemination). If an embryo develops from the egg+sperm concoction, it is then introduced into the woman’s womb. If the wee embryo accepts this new home, a normal pregnancy can be achieved.
Usually, women take medications prior to the IVF harvesting to boost their egg production. These fertility drugs may increase the chances of one, or many, of the eggs “taking” to the IVF procedures, successfully producing an embryo. The multitude of eggs harvested for the IVF procedure may be used at that time or frozen for later attempts.
Some women opt to have multiple embryos placed into their womb at once, again to increase their chances of at least one of the embryos developing into a healthy baby. This can lead to multiple births, including twins, triplets…or even octuplets. Others have their unused harvested eggs frozen to be used, or donated, at a later time.
Although it sounds simple enough, IVF is anything but. It is not only costly financially, but emotionally. There could be constant tests (both in facility and at home), the depression of procedures not working, the sorrow of losing an embryo during development, miscarriages, still births, failed insemination attempts, side effects of medications, the constant wondering “what if” and “when.” It takes a resilient heart. And plenty of women and couples endure. And many have successful births…yet, many do not.
Fresh embryo transfers
Fresh embryos are just that : fresh; not frozen. Eggs are harvested from the ovaries, and the clinics inseminate the eggs. Once fertilization takes place, embryos begin to form. Two to three days later, the woman is back in the clinic having the embryos transferred to her uterus (through a small tube device inserted through the vagina and cervix). Timing is critical, as there literally is no time to waste. And if conditions aren’t *just right*, the transfer may not take.
Frozen embryo transfers (FET)
Much like fresh embryos, the eggs are harvested, inseminated, and fertilized. The resulting embryos are frozen for later use, although some may not survive the thawing process. The longest-frozen embryo, with a successful birth, was a 20-year-old frozen embryo! Twenty years! The mother was a proud 42-year-old woman!
Over the years, the processes have changed for freezing eggs and embryos. Now the preferred method is vitrification. Vitrifi-what-tion? A very, very, VERY fast way of freezing. Consider it like flash-freezing a bag of peas. Fast, effective, and preserves quality. Vitrification now allows for a thaw survival rate of greater than 95%! Amazing, considering in the past using the slow-freeze method, a lot of eggs and embryos were lost during the thaw.
Studies have indicated that frozen embryo transfers yield a higher success rate than fresh transfers, boasting up to a two-thirds increase in successful pregnancies. Why? Theories have to do with fertility medications stripping the lining of the uterus from it’s cushiony-goodness (endometrial lining), creating a suboptimal home for the embryo. Fresh transfers don’t offer a lot of time to optimize the uterus, and the women are still recovering from their recent egg harvest (their bodies may be stressed, bloated, or in pain still). Meanwhile conditions can be timed (allowing the lining to rejuvinate, the woman to heal) with frozen-then-thawed transfers. There is far more control in the hands of the doctors and women.
Endometriosis and infertility
It is widely accepted as common knowledge that Endometriosis can cause infertility; however, it may not be well-known how or why it does so. They say 30%-50% of women with Endometriosis struggle with infertility. It may affect egg and embryo quality, or weaken uterine lining for implantation of the egg, or the inflammation and immune system responses may breed a less-than-optimum fertile environment in the body, or the scar tissue or implants may lead to blocked/twisted/damaged ovaries or Fallopian tubes, or it may just lead to a greater chance of miscarriages. Dr. Glatstein of IVF New England explains how Endometriosis may interfere with fertility in a short video here.
Endometriosis and IVF
The Society for Assisted Reproductive Technology (SART) released figures from 2013 of IVF procedures performed in women with Endometriosis, and the success rates of a live birth.
Using thawed embryos (aka once frozen…), the following percentages of live births were achieved in women with Endometriosis:
- Women younger than 35 years old : 42.3% (out of 823 cycles)
- Women between 35-37 years old : 39.8% (out of 414 cycles)
- Women between 38-40 years old : 38.1% (out of 227 cycles)
- Women between 41-42 years old : 29.8% (out of 48 cycles)
For comparison, IVF using fresh embryos in women with Endometriosis were :
- Women younger than 35 years old : 42.0% (out of 1,818 cycles)
- Women between 35-37 years old : 29.8% (out of 721 cycles)
- Women between 38-40 years old : 21.1% (out of 427 cycles)
- Women between 41-42 years old : 14.7% (out of 116 cycles)
Unfortunately, I do not know the Stages of Endometriosis with any of these women, nor their pre-IVF treatment for their Endo.
While some doctors believe in laparoscopic surgeries prior to IVF treatments to increase the chances of a successful procedures, others do not share those beliefs. Studies exist which support both ideas : endometriosis does (and does not) affect IVF outcomes…Just as our disease is a great big gray area, so is IVF and Endo…Other studies have shown that the removal of endometriomas from the ovaries may reduce ovarian reserve and hinder the efforts of egg retrieval for IVF. If you would like to consider surgery prior to IVF treatments, please have a few long discussions with your doctor about the potential influence with IVF procedures.
Studies & Things
In 2005, a study examined the differences of successful pregnancies and live births in women with Stage I & II Endometriosis versus women with Stage III & IV Endometriosis. Ninety-eight (98) women with confirmed Endometriosis underwent IVF between 1996-2003. Each cycle using frozen embryo transfers had higher success rates than those without. It also found that women with Stage I & II Endometriosis were more likely to have successful IVF procedures, but women with Stage III & IV had less successful chances. “Stage III/IV endometriosis means a worse prognosis for IVF/ICSI treatments compared to milder stages or tubal factors.” The authors suggested implanting two embryos in women with Stage III or IV, to increase the chances of a successful live birth.
In 2011, an Indian woman was the first successful pregnancy in Pune, India having used FET. Her eggs were harvested on one day, fertilized the next day, the embryos were frozen, and implanted five months later. At the time the article was written, she was successfully pregnant in her first trimester.
In 2011, a study was performed by reviewing scientific and medical literature to find out if using fresh or frozen embryos in IVF protocols increased the chances of live births in women with Endometriosis. They reviewed the figures for women from 2000 to 2008, and 415 women had Endometriosis (representing 5.7% of the women in the entire literature review). Their review found that there was no statistical differences between women with Endo and women without Endo using fresh embryos for IVF (as far as the chances of clinical pregnancy rates, live births, or miscarriages). However, they did find that when using frozen embryos (FET) with Endometriosis sufferers, the clinical pregnancy rate was much higher (18.2%). This study suggested that women with Endometriosis should treat with GnRH antagonists (i.e, Lupron Depot), to help “better the environment” for the embryo, hopefully increasing the chances of a pregnancy and successful live birth.
Another 2011 study followed 29 women with Endometriosis who had multiple prior failed IVF attempts. Of the 29 women, all underwent new laparoscopic surgeries to clear their bodies of Endometriosis and adhesions. Twenty-two of them conceived after their surgeries; 15 naturally and 7 using IVF procedures. The authors suggest laparoscopy may be a valid treatment option for Endo sufferers seeking to conceive and that the Stage of severity of Endo may affect the outcome of the pregnancies:
- Of the four women with Stage I Endometriosis, 100% of them conceived;
- Of the six women with Stage II, 83% conceived;
- Of the six women with Stage III Endo, 83% conceived; and,
- Of the 13 women with Stage IV Endo, 62% conceived.
An article published in April 2013 by Dr. Ryan Funk shared a story of a woman with Endometriosis who added acupuncture to her pre-IVF routine. Previously, she had a laparoscopic surgery to excise the Endometriosis, had one Fallopian tube removed, and has unsuccessfully undergone five fresh embryo transfers and two frozen embryo transfers. After a consultation with Acubalance Wellness Centre, she decided that two months prior to her FET procedure, she would start acupuncture, as well as dietary and supplement changes according to their recommendations. For those two months, she attended weekly acupuncture sessions and noticed a difference in her periods and pain. Because of those differences, she decided to postpone her FET procedure and continue acupuncture and her new dietary/supplement/herbal lifestyle. Two months later, while keeping up with her new routine, she became pregnant. Naturally.
A July 2013 study reviewed the data and studies of 8,984 women, analyzing their Endometriosis stages and infertility treatments. The 13-page study concluded that women suffering from Stage III and IV Endometriosis had poorer implantation and pregnancy rates than those with Stage I and II in IVF treatments. Interestingly enough, the authors concluded the study by stating, “A demonstration of reduction of IVF clinical pregnancies in women with Stage III/IV endometriosis does not necessarily mean that treatment of endometriosis will restore the clinical pregnancy rates to the level expected in women without Endometriosis. Therefore this evidence does not justify advocating medical or surgical treatment of Endometriosis for these women, as a favourable risk benefit analysis of intervention in this clinical context is currently absent.”
At a 2013 Medical Conference (put on by the Endometriosis Foundation of America), Dr. Jamie Grifo spoke about the importance of conducting pre-implantation genetic diagnoses on potential embryos to help achieve more successful pregnancies. Dr. Grifo said, “Biological clocks tick a little bit faster for women who have endometriosis,” and would like to see women with Endometriosis have their eggs frozen earlier for optimum fertility. He ends his speech with these very powerful words, “Egg freezing is an option to preserve fertility. It is a hope, it is not a promise. It is an option, not an obligation. Not something people should do but something that people should know about. It is very costly, it is not 100 percent…Give patients informed consent. Let patients make the decisions, let them know their options and let them make decisions. Do not let someone to make decisions for you…” You can watch the video and read the transcript here.
A 2014 study found that women who received acupuncture prior to their FET procedures had higher rates of embryo implantation, clinical pregnancy and live birth than women who did not receive acupuncture. The acupuncture was shown to also improve the pattern condition and blood supply of the endometrial lining. It also “improved HOXA10 expression. Higher HOXA10 is associated with greater endometrial receptivity and good pregnancy outcomes. HOXA10 expression is lower in the uteri of women with hydrosalpinx, PCOS, and endometriosis.” What’s HOXA10 (I had to look it up, too…) : it’s a protein gene. Sciencey stuff…But how much acupuncture did these women in this study receive? They underwent six sessions per cycle for three cycles (so, doing that math that’s about six times a month for three months).
Dr. Lim wrote in her 2015 blog about a study that found that women who incorporated acupuncture into the lives and IVF treatments has a 91% increased chance of a live birth as opposed to women who did not receive acupuncture. The study concluded that “Acupuncture given with embryo transfer, improves rates of pregnancy and live birth in women who are undergoing in vitro fertilisation.”
What Other EndoSisters are Saying
An article published in 2009 follows the story of “Maria,” and her attempts to conceive. She and her husband gave up drinking and consulted with a nutritionist. She underwent monitored cycles, including regularly-scheduled scans and blood tests. She also used a daily inhaler, which suppressed all hormones, as well as injections to accelerate egg production (she notes these injections caused her Endo to flare up…). After having her eggs harvested, three days later she returned to have the embryos transferred, and she learned two weeks later that she was pregnant. Another three weeks passed before she learned they were having twins! When she had her eggs initially harvested, they had them frozen. When she and her husband decided it was time to “try again,” she contacted the center to schedule a transferring procedure for the remaining embryos. She was devastated to learn that all six embryos did not survive. They pressed forward and scheduled an IVF procedure for later that month, and once again conceived twins. She offers this bit of advice, “Results can be skewed by all sorts of things, so go and talk to the doctor yourself. Take their advice: if it means sacrifices like not drinking for a few months to increase your chances, just do it.”
In 2012, “9ay” asked Dr. Fiona McCulloch what could be done naturally to help increase her chances of a keeping her Endo at bay and achieve a successful IVF pregnancy. 9ay was diagnosed with Stage IV Endometriosis and had undergone excision surgery four months prior. Since, she had tried to conceive naturally and by fresh embryo IVF, but failed. To aid in her IVF journey, she was taking Lupron to down regulate, and was also taking Estradiol Valerate tablets to increase her endometrial thickness. Dr. McCulloch responded that she has had several Stage IV Endo patients achieve successful IVF pregnancies. She suggested taking EGCG tablets (from green tea) to fight inflammation and cut out gluten to help avoid any immunological issues it may create. She additionally suggested undergoing allergy tests for additional Endo triggers, as well as a complete thyroid panel to check for thyroid antibodies.
In 2012, Sarah wrote about her IVF journey on Bloggers for Hope. A few years after her first excision surgery, Sarah and her husband decided it was time to try to make a family. She stopped her birth control pills and immediately suffered horrible periods and pain. A few months later, she endured yet another surgery to remove her Endo implants and adhesions. She and her husband tried to conceive naturally for a few moths, but to no avail. She took Clomid and underwent three separate IUIs (a procedure where sperm is injected directly into the uterus during ovulation). When those did not work, they put her on Lupron for a month (to regulate her estrogen levels), followed by an IVF cycle. She was also on Folostrum at that time. Her doctors retrieved 23 eggs, inseminated 19 of them, froze a few, and transferred two of them five days later. *voila* Henry was conceived. Later, when they decided it was time to try again, they thawed the remaining six frozen embryos. Two did not survive the thaw, and the other four were transferred during two separate FET sessions; each procedure failing. Sarah writes, “After the final FET we knew we were done. Both financially and emotionally we were at our limits. We decided to walk away and hold on to how lucky we are to have our sweet Henry.”
In July 2013, “luv01314” posted in a forum that she has Stage IV Endometriosis, along with Adenomyosis. She had previous failed attempts at fresh IVF, a laparoscopic excision surgery in April 2013, as well as naturally trying to conceive for two months, without success. She was going to try FET next. Many women responded with their own stories (some successful, others not). The difference? It all depends. On what? On the woman, the method of freezing, the odds, Luck, God’s will, the Fates, etc. There really is no way of knowing. Some women used Lupron or birth control pills to prep for the IVF; others did not. One woman was quoted a 98% success rate for FETs, yet her child died in a miscarriage. There is no guarantee.
In 2013, an Anonymous EndoSister was able to conceive after her fourth fresh IVF treatment. She had some frozen embryos to try again later, once their son was a bit older. Her question was how long can she wait before her Endo (and age) became a damning factor in IVF procedures. Sisters offered advice of her trying to get another laparoscopic surgery before attempting FET procedures (to clean out her body and give those embryos a fighting chance). Others suggested a three-month course of Lupron Depot prior to the FETs. And yet others recommended both the laparoscopy and the three-months of Lupron Depot prior to trying the FET procedures. I don’t know what course, if any, she chose.
Did I Answer the Question?
I’m not quite sure I did. It seems each IVF (whether fresh or frozen) experience was an individual experience, none in common with the other. It depends on sooo many factors, but what I did find is:
- If preparing for an IVF procedure, take care of your body. Attempt to reduce your Endometriosis (and inflammation) with diet or supplements (always discuss with your doctor first). Try to give your body the best fighting chance it has to not only be healthy, but to create a warm and welcoming home for your child.
- Consider acupuncture prior to IVF. Studies have shown it may help increase your chances of conception.
- Perhaps talk to a nutritionist. What food triggers your Endo symptoms? What food calms your symptoms? What food may be best to facilitate the IVF and health of your body, and the health of your child?
- The Stage of Endometriosis may affect the outcome of IVF treatments, and the use of more embryos during IVF may be warranted.
- Fertility drugs, hormones, and GnRH antagonists may be a viable regimen prior to harvesting eggs and implanting embryos. Many women have taken them and had successful IVF procedures. Then again, many have not.
- Talk to your doctor. Not only about your fears and questions, but about your desires. Discuss alternatives to medication you may not wish to take. Ask for candid answers regarding percentages and best-case/worst-case scenarios. Be informed.
- Techniques for freezing, and thawing, eggs and embryos has changed over the decades and has a far greater success rate than in the past.
- And most importantly : you are not alone in this struggle. You have friends and family, as well as the countless other women who have endured (and are enduring) the same thing. Seek out support groups or online forums. Find that camaraderie, those shoulders to lean on, the advice of those who have been there.
What will be, will be. Wishing all of you the best of luck in your efforts to create a family. I gave up long ago, and am at peace with that decision (although sometimes it still stings). May you have the strength to endure.
Acubalance Wellness Centre – (Article, April 2013) Endometriosis Pregnancy Success : A Case Study
Advanced Fertility Center of Chicago – IVF & Lupron
American Society for Reproductive Medicine – Endo and infertility
Babycentre – “luv01314” Q&A forum
BJOG – (Article, July 2013) The Effect of Endometriosis on In Vitro Fertilisation Outcome : A Systematic Review and Meta-Analysis
Bloggers for Hope – Sarah’s story of infertility and Endometriosis
Chances Our – blog with notes from Endometriosis Conference 2013
CNY Fertility – Vitrification for Embryos and Eggs
DC Urban Moms and Dads – Anonymous Endo Sufferer’s IVF Journey
Dominion Fertility – Do I Need Endometriosis Surgery if I am Planning to Pursue IVF
DrG’s Fertility Blog – Do I Need Endometriosis Surgery if I am Planning to Pursue IVF
Dr. Helena Lim – The Benefits of Acupuncture in IVF
Endometriosis Foundation of America – 2013 Medical Conference Video and Transcript of Dr. Jamie Grifo, “Egg Freezing as an Option for Endometriosis Patients”
Fertility Authority – Infertility Research Shows Frozen Embryo Transfers Yield Higher Pregnancy Rates
Fertility Centers of New England – IVF is a Very Good Treatment for Infertile Women with Endometriosis
Human Fertilisation & Embryology Authority – Embryo Transfer
Human Fertilisation & Embryology Authority – Maria’s IVF success story
Information Acupuncture Infertility Research – (Abstract, 2014) Acupuncture Improves Receptivity of Endometrial Lining in IVF Frozen Embryo Transfer
IVF1 – Endometriosis IVF
IVF.ca – “9ay” Q&A with Dr. Fiona McCulloch
IVF New England – 2014 Video of Dr. Glatstein explaining how Endometriosis can interfere with fertility
Medline Plus – IVF
OBGyn.net – (Article, June 2011) Laparoscopic Treatment of Endometriosis in Patients with Failed In Vitro Fertilization Cycles
Oxford Journals – (Article, May 2005) Effect of Endometriosis on IVF/ICSI Outcome : Stage III/IV Endometriosis Worsens Cumulative Pregnancy and Live-Born Rates
Shady Grove Fertility – IVF : What You Need to Know
Society for Assisted Reproductive Technology – stats re IVF and FET
The Infertility Center of St. Louis – Baby Born from 20-Year-Old Frozen Embryo
The Times of India – (Article, Nov. 2011) Woman Conceives Successfully Through ‘Frozen Eggs” Technique
US National Library of Medicine – (Abstract, June 2011) Live birth rate in fresh and frozen embryo transfer cycles in women with Endometriosis
Victoria Fertility Centre – Frequently Asked Questions
Vitrolife – vitrification explanation
~ Again, I am a layman. I do not hold any college degrees, nor mastery of knowledge. Please take what I say with a grain of salt. If curious, do your own research 😉 Validate my writings. Or challenge them. And ALWAYS feel free to consult with your physician. Always. Yours ~ Lisa