Repeated implantation failures and miscarriages: what we can learn from Greece

Patients who write to me after several failed attempts all say the same thing: ‘Nobody has explained to me why’. More often than not, there is no single reason, and we have to accept that. But there are tests that haven’t been carried out, questions that haven’t been asked, and options that aren’t permitted in France. This article makes no promises; it simply lists what is available.

What exactly are we talking about?

We are talking about recurrent implantation failure, generally defined as three transfers of good-quality embryos without resulting in a pregnancy, or after a cumulative total of four embryo transfers. We are talking about recurrent miscarriages, defined as two or more consecutive losses. The two situations overlap to some extent, as do the diagnostic procedures.

The basic assessment, which is often incomplete

Before any sophisticated techniques are considered, a reputable clinic will ensure that the basic assessment is complete and up to date:

• The uterus: diagnostic hysteroscopy to check for polyps, septa, adhesions or adenomyosis. This is the most cost-effective test and the one most often overlooked.
• Karyotypes for both partners, to check for a balanced chromosomal abnormality.
• A thrombophilia assessment and screening for antiphospholipid syndrome, for which treatment is simple and effective if the result is positive.
• Thyroid function, vitamin D, prolactin and glycated haemoglobin.
• Semen analysis: sperm DNA fragmentation, which is often overlooked when the standard semen analysis is normal.

What Greece permits and France restricts

The first point is PGT-A, the pre-implantation genetic testing for aneuploidy, which is not authorised in France unless a known genetic disorder is present. In women over 38, a significant proportion of treatment failures and miscarriages are due to aneuploid embryos; the test helps to rule these out. In younger women, its benefit is less pronounced but may be considered following several unexplained miscarriages.

The second factor is faster access to specialised tests and consultations: a hysteroscopy within a few weeks, or a consultation with a haematologist or reproductive immunologist without having to wait six months. It is not that Greek medicine is any different; it is simply that the private healthcare system there is more responsive.

The tests under discussion

Certain tests are offered everywhere, including by Greek clinics, without any proven evidence of their usefulness. I prefer to name them:

• The endometrial receptivity test (ERA), which aims to identify the personalised ‘implantation window’. Recent randomised trials have shown no benefit for the majority of patients.
• NK cell testing and immunomodulatory treatments (intralipids, immunoglobulins, corticosteroids): the evidence remains contradictory, and these treatments are not without risk.
• Endometrial scratching, the benefits of which have not been confirmed.
• Intrauterine PRP, currently under evaluation.

This does not mean that a clinic offering these treatments is dishonest. It means you should ask: ‘What is the evidence, in my case, and how much does it cost?’ A good doctor will answer you without taking offence.

Changing strategy

After several failed attempts using your own eggs, particularly if you are over 40, the question of egg donation eventually arises. It is not an easy topic to broach, and I never raise it during the first consultation. But statistically speaking, this is the change that makes the biggest difference to your chances: pregnancy rates per transfer using donor eggs are around 50 to 60 per cent, regardless of the recipient’s age. The Greek legal framework for egg donation can be found here.

How to approach a Greek clinic after previous failures

Send a complete file: reports from each attempt, the number and quality of embryos, the protocols used, and the results of any tests already carried out. A doctor who takes the time to read this file before the video consultation is a doctor who is looking for a cause, not just a standard protocol. This is what I check for every patient before arranging the first appointment.

Frequently asked questions

Source: https://fertilitegrece.com/en/blog/implantation-failure-miscarriage-greece/ — Triada Baloukoudis, IVF patient coordination in Greece. General information, not medical or legal advice. Printed on