Dear Professor Winston,
I’m 31 and so is my husband and after about 18months of trying to conceive naturally and having various tests and procedures including a hysterosalpingogram and a hysteroscopy (all clear) we decided to go for IVF. We are both healthy, eat well and aren’t under or overweight and don’t smoke. I have been checked for PCOS and endometriosis and been given the all clear. My husband’s sperm is also fine. The only problem ever discovered was that when my fertility clinic attempted a mock transfer they couldn’t get through my cervix easily even with me sedated. This is in fact why I had the hysteroscopy to dilate my cervix before the actual transfer. By the time of my actual ET my cervix had again become very tight and difficult to pass through so the ET was very difficult. That IVF cycle failed. We have just found out that our second cycle of IVF has also failed with 2 very good quality embryos put back in by a transmyometrial transfer which went very well. The difficult decision now for us is whether to go for a third cycle as we have another 2 very good quality embryos frozen or to take a break and try again naturally for a while. I was just wondering whether the problems with my cervix and the fact that my uterus is acutley anteverted could be causing the problems for us conceiving naturally? and if the first 2 cycles of IVF with good quality embryos have failed to implant, could a third be different? The only other thing to mention is that my periods have always been irregular and extremely painful but with all the tests I have had there seems to be no reason for this. I ovulate normally each month and had a normal AMH result for my age.
With thanks and kind regards, S

Reply…

Dear S,

I do find it disappointing when people continue to refer to “good quality embryos”. I do not know how often I have reiterated this on this website, but practically speaking the only clearly good quality embryo is generally one which produces a successful pregnancy. It is completely impossible to say by looking down a microscope whether an embryo is of good quality. It is possible to say it looks normal, or that it has grown well, but an examination by a microscope cannot give detailed information about the genetics or fine molecular information needed to assess whether the embryo is really like to become a baby. It is true that an embryo which has divided normally and grown reasonably well is a bit more likely to become a baby but really that is all.

It is certainly true that if embryo transfer is more difficult or more traumatic for some reason – usually problems with a very tight cervix, for example – then a pregnancy is less likely. To fail to get pregnant after one very traumatic transfer is highly likely, and then to fail after transmyometrial transfer just once is simply well within mathematical probabability, so a third attempt at ET would seem highly desirable. Obviously I haven’t assessed your precise problem myself but I think I would be inclined to see whether careful dilatation of the cervix at the beginning of the ET cycle (under general anaesthetic) is worth considering. Also, some readers may think I am obsessed by the idea of hysterosalpingograms, but I personally don’t entirely trust hysteroscopy in this situation. A series of X-rays of the uterus taken from slightly different angles may reveal whether there is a congenital abnormality of the uterus which accounts for the difficulty in getting through the cervix and also for the acute anteversion that you describe. This isn’t that likely, but it would be helpful to confirm that there is a proper chance of normal implantation (and that this is not the reason for your difficultly with menstruation). Also, I should add that at the time of cervical dilation (no doubt they have done this already) that a probe is gently passed into the uterus to measure its total length. This would be further confirmation that womb is normal and that the issue with the tight cervix is merely an isolated problem.

I hope these comments may be helpful,

Best wishes
Robert Winston

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