We set up a call with our doctor, who might I add now feels like a member of our family more than a member of our clinical team, to review the results. I can’t stress enough how having continuity of care impacts how I have felt about treatment. I feel supported in such a different way, where my doctor knows my face and my situation.

Anyway, the results you’ve all been waiting for (hah, I feel like I am the only one anxiously awaiting these)…

EndomeTrio:

ERA Test:
We have found out that I am “pre-receptive”. Here’s an excerpt from my clinic on what the receptivity test does:

“The rationale for the test is based on the fact that the endometrium will only allow the implantation during a finite time frame known as the window of implantation (WOI). If the embryo is delivered to the uterus too early or too late, when the window is closed, implantation cannot occur […] However, until the ERA test was developed, there was no meaningful way to measure it in any given individual. More importantly, the ERA was actionable: if the endometrium was found to be non-receptive a plan to optimize receptivity was provided.” (Source)

Pregnancy can’t occur if:

• the window of receptivity is missed
• the embryo isn’t mature enough
• the endometrium is not expressing the correct genes or is not in a receptive state

The idea of a window of receptivity exists in both natural conception and IVF.

In my particular case, a very specific window of transfer/implantation has been recommended – between 141-147 hours of progesterone. This means my endometrium wasn’t ready on the day of biopsy, and additional progesterone is recommended (so an ideal transfer would take place approx a day after the normal transfer date of day 5 for most frozen embryos).

Here’s a really good article that explains receptivity and how to interpret your results if you do the ERA: https://en.e-stork.com.tw/article/view/71

EMMA Test:
The EMMA test came back recommending vaginal probiotics for 10 days prior to FET. I have taken these before, but not every time. The recommended probiotic is Flora SAP.

ALICE Test:
Nothing found

UtimPRO
This test was the beast. This one is not done routinely, but due to my implantation failure and recurrent miscarriages, my doctor recommended I give it a shot. I don’t know anyone else personally who has had this test, but the findings were very interesting. Once again, I am happy to try anything and everything at this point in my journey.

I didn’t see the report directly, but given the recommendations I was able to draw a few conclusions.

1. Heparin was recommended for my FET. This likely indicates that a clotting disorder may be a factor in my repeat failure. Here’s a good study on use of Heparin in Assisted Reproductive Technology (ART): https://academic.oup.com/humupd/article/14/6/623/631770

2. Endometrial biopsy prior to FET was recommended (AKA scratching). SUPER excited to do that again (sarcasm). Scratching can enhance the receptivity of the uterus to the embryo. It’s not a guarantee, but it ‘can’ assist. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294834/

3. Addition of HCG – HCG can aid in the implantation of the embyro,

Experiments have indicated that hCG influences the level of hormones in the uterus and even within the embryo itself around the time of implantation. hCG may also influence cells involved in the immune response of the uterus to the embryo, allowing the uterus to accept the embryo.

Here are two good studies on adding HCG during FET and the outcomes.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9289495/
https://www.fertstert.org/article/S0015-0282(19)31176-8/fulltext

4. Addition of Seminal Plasma (basically intercourse one day prior to and one day after transfer)

“Seminal fluid contains several proteins that interact with cervical and uterine epithelial cells inducing active immune tolerance.” (source)

Studies are conflicted, but here are two that demonstrate benefits:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9979547/
https://www.iris.unina.it/retrieve/handle/11588/698105/212311/Saccone_et_al-2019-BJOG__An_International_Journal_of_Obstetrics_%26_Gynaecology.pdf


After reading all of the above, I am assuming that there’s a suspected immune response happening during implantation of an embryo in my uterus.

So how do I feel about this? Relieved to be honest. For the first time in our IVF journey, something actionable has come about that gives us hope. So many people have success in IVF during the first or second retrievals, and although my egg quality and our blastocyst production has taken a hit recently, this testing has made me feel more in control of my outcomes. Will it work? Who the hell knows.

The moral of the story here is that embryos are precious and everything should be done to ensure the ones we have actually implant. I am not sure why these tests aren’t offered more often before transfer, especially after subsequent failed implantation or miscarriage. I feel that I was over confident after our first egg retrieval, thinking “we made 7, we can make more easily!”. That wasn’t the case.

Going forward I feel more confident that any embryos we do create (fingers crossed), will have the BEST shot of survival. That we’re doing all we can on our end to make this dream a reality. I always tell my IVF friends, ADVOCATE ADVOCATE ADVOCATE for yourself in this process. Be it in asking for a test, pushing for a second opinion, making your wishes known. So many of us pay out of pocket for this, and we should use that power to do everything we can to achieve the outcomes we can for our future. You’re in the drivers seat, so don’t just sit there in the parking lot waiting for change to happen.

PS – I’ll be adding all of the studies I link to in my blog in my Resources page, once I have some time to organize them! If you know of a study that is informative that should be included, feel free to comment below!

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In September 1st my period came again and we started with a wonderful new clinic. I was nervous to make the switch. It meant new blood work, scans and building a new relationship with a new team (let’s be real though, there wasn’t much of one at the last clinic). I’m not sure I would have had the energy to keep going with the first one anyhow. It’s like kicking a relationship until it’s last breath. It felt like it was just time to call it. I felt like I deserved better. 

I called the clinic on cycle day one and we discussed then and there what our next steps would/should be. Did I want to forge ahead with a retrieval and get moving asap? Absolutely! But we decided before we made any more attempts that it would be smarter to do some further testing. 

We started with my AMH levels, last tested in April of 2022. My initial levels were 9.6 pmol/L, but now in September 2023 they had dropped significantly to 5.1 (for those on the ng/mL scale, it went from about 1.34 to .78). This officially put me in DOR (diminished ovarian reserve) territory. Scary stuff. Your AMH can fluctuate but I took this seriously. Going ahead, and looking back, it was becoming harder to get quality eggs and embryos. Our time was running out and the embryos we could get were becoming rare and precious. 

We decided with our new doctor (who is wonderful BTW) to do a mock cycle before doing another retrieval. This would delay our retrieval by 2-4 months but it would be instrumental in ruling out and identifying any barriers to carrying a healthy pregnancy.

Mock cycles are often debated in the fertility community. Some doctors are all for them, and the myriad of biopsies that can go alongside them. There is mixed evidence, or maybe just not enough evidence to convince all doctors of the value of these tests, but I wanted to take the kitchen sink approach. We were still very much in unexplained infertility territory, so anything that could explain what was happening was welcome.(I’ll link to some relevant studies below in case you want to read them)

Four endometrial biopsy tests were recommended as options with one strongly urged over the others. I decided to do all of them. 

EndomeTrio (3 tests)

ERA (Endometrial Receptivity Analysis)

The ERA test checks the receptivity of the uterine lining to find out if it is lining is receptive to embryo implantation at the time of a normal transfer. The test could indicate a different amount of progesterone in preparation for future embryo transfers. (The ERA test resulted in a 73% pregnancy rate in patients with implantation failure) 

(https://www.igenomix.co.uk/genetic-solutions/endometrio-clinics/#:~:text=The%20ERA%20test%20evaluates%20the,personalised%20embryo%20transfer%20(pET).)

ALICE (Analysis of Infectious Chronic Endometritis) 

ALICE detects the bacteria causing chronic endometritis (CE) and identifies the most common bacteria causing it and helps clinicians to recommend appropriate antibiotic and probiotic treatments.

EMMA (Endometrial Microbiome Metagenomic Analysis) 

EMMA evaluates the uterine environment at the microbiological level by analyzing it’s  microbiome. It can indicate whether the uterus has the optimal microbiome for embryo implantation.

UTIMPRO (strongly encouraged by our doctor)

UtimPro is a biopsy that analyzes the immune profile of your uterine environment and response to foreign cells (embryos, etc). It tests for natural killer cells and it can indicate a very specific customized protocol for individual patients. 

To do a mock cycle, you basically proceed as if you’re planning on doing a frozen embryo transfer. I started on Estradiol on day one, and similar to a FET, my lining was monitored throughout my cycle. I did 5 appointments with my friend Wanda, and it took a little while to get to the needed 7.5mm minimum uterine lining thickness required for the biopsy. I introduced progesterone on day 28 (pretty normal for me as I struggle with thin lining issues) – both as suppositories and intramuscular injections. My biopsy finally took place 6 days later on October 3rd. 

I’ll stop here to say, by this time I had met with my actual doctor either on zoom or in person 5 times in one month. He was also the one to personally do my scans and my biopsy. Seeing that smiling familiar face made all the difference. Technically the appointments were the same, but patient care was worlds ahead with the new clinic. From the receptionists and nurses to the clinic itself and their professionalism and timeliness. It made the experience better many times over. 

The biopsy was…. Not fun. Not going to sugar coat it. Because of the things being tested, the biopsy only allows you to take Tylenol as a pain killer and is fully unmedicated otherwise. I managed to convince them to give me a Ativan to take as I tend to have a sensitive cervix. The procedure requires them to use the speculum, and sometimes a cervical clamp, and insert a tool into the uterus to scrape the lining. It’s as gross as it sounds. The doctor told me it would hurt and I prepared myself. He told me I could swear at him if I needed to, that it would last 10-15 seconds and I’d have some severe cramping. The nurse offered to hold my hand.

They went in with the pipette (the tool for the biopsy scrape), and I was surprised it didn’t hurt more to be honest. It did suck, very much. But I tolerated it and they applauded me for handling it better than most do. Once the procedure ended, the cramping stopped. It turned to mild tenderness, and I spotted a tiny bit following the procedure. After that, I was good to go.

The test results take 2-3 weeks on average for the EndomeTRIO and 4-6 weeks for the UTIMPRO.

The doctor put me on Estradiol again for 5 days, but I began bleeding 3 days later for my next period. All in all, I think it was worthwhile. The overall cost was around $3400 CAD including meds, the time it took was 33 days for the cycle, and the recovery was almost immediate.

Now, we wait for those juicy results.

Studies on the above mentioned tests:

The Uterine Immune Profile May Help Women With Repeated Unexplained Embryo Implantation Failure After In Vitro Fertilization (2016)

Comparison of the Effectiveness of Endometrial Receptivity Analysis (ERA) to Guide Personalized Embryo Transfer with Conventional Frozen Embryo Transfer in 281 Chinese Women with Recurrent Implantation Failure

Is Endometrial Receptivity Assay (ERA) Useful in Patients with
Repeated Implantation Failure Undergoing Single, Autologous Euploid
Embryo Transfer?

The Endometrial Microbiome and Its Impact on Human Conception

Characterization of the Endometrial Microbiome in Patients with Recurrent Implantation Failure

The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology

The effect of chronic endometritis and treatment on patients with unexplained infertility

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