After IVF: Implantation, the 2-Week Wait, and Failure

Chapter 7

In the previous chapter, we finished the IVF process after embryo transfer. Now, it’s time to go over what happens after the IVF transfer. The post-transfer process can work out in many different ways. In this chapter we will talk about:

  • The dreaded 2-week wait and implantation
  • The pregnancy test
  • Negative outcomes of IVF     

When we are done with this chapter, you will have complete knowledge of implantation, pregnancy tests and how they work, and possible negative outcomes of IVF. For information on pregnancy and positive outcomes, you can skip to the next chapter.

IVF 2-week wait

After the embryo transfer is completed, it’s time for the 2-week wait. This is a time dreaded by most IVF patients. Until now, they had doctor’s visits nearly every day. And now, they’ll have to wait 10-14 days until they can take a pregnancy test. 

Hopefully, during the 2-week wait, the embryo will implant, start growing, and produce beta-hCG. 

During the 2-week wait, it’s important that patients return to their normal lives as much as possible and avoid stress.

What to do during 2 week wait?

The best thing you can do during the 2-week wait is to try and go back to your daily routine as much as possible, and to find positive and productive distractions.

Patients shouldn’t spend their time obsessively checking for implantation symptoms or taking pregnancy tests that can be faulty. These practices can induce stress, cause emotional distress in case of negative results, or potentially cause false hope.

Instead, try focusing on things that will reduce your stress levels:

  • Do not forget to take your medications such as estrogen, progesterone, or blood thinners as per your doctor’s orders.
  • Spend time with your friends and family as much as possible. Do not be afraid to ask for support. If you aren’t able to find the support you need from your circle, do not be afraid to look for support in online groups and read the stories of people you share experiences with.
  • Continue with light exercises such as walking, yoga, and hiking for both physical health and mental health benefits. Take up meditation, prayer, and breathing exercises to reduce your stress and anxiety.
  • Take up a new, stress-relieving hobby such as painting, knitting, etc. Painting and knitting are especially great options, because they depend on repetitive movements that will occupy the mind and allow for creative expression. 

Implantation

After transfer, the embryo needs to be implanted into the uterine lining to survive and become a fetus.

The first step in the implantation process is the hatching of the blastocyst from the zona pellucida. If hatching doesn’t occur, the embryo cannot implant. 

After hatching, the embryo binds to the uterine lining. For the embryo to survive, the uterine lining should be thick enough, at around 8 millimeters. If the uterine lining isn’t thick enough, the embryo cannot implant.

With implantation, the embryo eats away at the uterine lining and builds new veins and systems in the uterus so it can receive nutrients from the mother to grow. This “eating away” process can cause some spotting when it happens, but not with all patients.

After implantation, the embryo will produce a hormone called human Chorionic Gonadotropin, also known as the pregnancy hormone, and the amount of beta-hCG should double every two days as the embryo grows.

How does IVF implantation work?

IVF implantation works the same as natural implantation. The only difference is that the patient doesn’t have an idea of how viable their uterus is for the implantation to occur or to support a pregnancy during natural conception.

With IVF, there are tests, medications, and procedures available to increase the chances of implantation, especially for people who are dealing with recurrent implantation failure. 

Tests such as ERA, EMMA, ALICE, etc. can be used to closely examine the uterine lining and to predict the best time for implantation. If the embryo is unable to hatch on its own, or if it’s a frozen cycle, assisted hatching can be used to improve implantation chances.

When does implantation occur?

With natural conception, the embryo reaches the blastocyst stage on day 5 and has traveled to the uterus from the fallopian tubes. Implantation usually takes place 8-9 days after fertilization. However, in some cases, it can occur as early as day 6, or as late as day 12. So, with IVF, you can expect the implantation day to be a few days after transfer, if not a week.

5-Day Blastocyst Implantation Timeline

IVF Late Implantation

As mentioned above, sometimes after transfer the embryo can take a week to implant. Late implantation is associated with miscarriages, but there is no direct correlation between the two.   

Late implantation doesn’t usually show symptoms during the 2-week wait. Some people might experience implantation bleeding, some might not, so it’s not a good idea to jump to conclusions. The only way to find out about late implantation would be to get your beta-hCG levels checked.

What can I do to help with implantation after IVF?

After transfer, implantation depends on the embryo and the uterine lining, and not much can help with the process. Patients should resume their daily activities while avoiding high-impact or high-intensity situations.

Doctors usually recommend patients avoid high-impact physical activities such as running or weightlifting. Also, patients are advised to avoid intercourse and orgasms to not disturb the uterus. While myths about jumping, carrying heavy loads, or the embryos falling are obviously not true, it’s still a good idea to avoid strenuous activity.

However, avoiding physical activity doesn’t mean that you need to be on bed rest. Unless there is a medical reason approved by the doctor, patients should not be on bed rest after transfer. Bed rest has no positive effect on IVF outcomes and can lead to failure in some cases because it can make the patient depressed or anxious.

Why can’t you have sex during 2 week wait?

After transfer, most fertility specialists will advise you to abstain from intercourse until your pregnancy test. This is also known as pelvic rest. There is conflicting evidence regarding whether having sex affects implantation or live birth rates. Still, most doctors will be cautious and recommend you abstain from intercourse for at least a week after embryo transfer.

There are two reasons why sex is discouraged during the 2-week wait. First, after the transfer, the reproductive system is more vulnerable to infection. Having an infection at such a critical time as your implantation window can be problematic, and doctors would like to prevent that as much as possible. 

The second reason is that having penetrative sex and orgasm can cause the uterus to contract. Within this critical implantation window, it’s best to avoid any activity that can cause the uterus to move and contract in a significant way, like sex and high-impact exercises.

IVF Implantation Symptoms

  • Implantation bleeding is the most talked-about symptom after IVF transfer. Implantation bleeding is caused by the embryo eating away at the uterine lining and building new blood vessels so it can get nutrients from the mother. This action can cause some spotting. What’s important to know about implantation bleeding is that not every woman experiences it. So if you’re not experiencing any spotting or discharge during the 2-week wait, do not be alarmed. However, implantation bleeding is spotting, so if you’re experiencing excessive bleeding, please contact your doctor.
  • Cramping and lower back pain after the transfer is also common and expected. You’ve just gone through a surgical procedure that involves your abdomen. Your reproductive tract is probably still swollen, which can put pressure on other organs.

IVF 2-Week Wait Symptoms

Aside from symptoms of implantation, some common side effects and symptoms that started during ovarian stimulation can continue during the 2-week wait. During the 2-week wait, symptoms such as heightened emotional state, swollen breasts, bloating, constipation, or diarrhea may persist.

If the patient is pregnant, with the rise of beta-hCG levels in the blood, there is a chance of developing Ovarian Hyperstimulation Syndrome. Usually, the risk of OHSS is evaluated beforehand and prevented completely. But in some cases, patients who were not at risk for OHSS can develop it during pregnancy.

How soon after IVF implantation can I test?

After implantation, hCG levels will start to rise and can be detected in the blood or urine. Even though most patients would like to see if they’re pregnant or not, it’s not recommended that patients use an at-home pregnancy test after IVF.

  • At-home tests do not measure hCG levels, only its presence.
  • You might still be very early in your pregnancy to produce enough hCG to be detected via an at-home test. A negative result may affect your mood and motivation. 
  • At-home tests can be faulty or can give faulty results; negative when there’s a pregnancy, positive when there’s not. The result of the at-home test might not match with the blood work or the ultrasound, which can affect your mood. 
  • If you’ve used hCG during ovarian stimulation or have OHSS, an at-home test can give you a false positive. For the most accurate results, you should wait at least 10 days after embryo transfer before taking a test.

IVF Pregnancy Test

After the 2-week wait, a pregnancy test is performed by the doctors to see if the patient is pregnant or not. In a medical pregnancy test, the doctors will check the beta-hCG levels in the blood. But how is this different from an at-home pregnancy test?

What is a beta-hCG test in IVF?

An at-home pregnancy test will detect the presence of hCG in the urine but not its levels. With a blood test, you can get an accurate reading of your beta-hCG levels, which can tell you if you’re having a chemical pregnancy, an ectopic pregnancy, a clinical pregnancy, or implantation failure.

The reason why doctors wait 2 weeks between embryo transfer and the pregnancy test and discourage patients from taking at-home tests is to prevent false positives. During ovarian stimulation, if the patient used hCG to grow follicles or as a trigger shot, it remains in the system. This is why at-home pregnancy tests can give a false positive.

With a professional pregnancy test, doctors are able to wait until hCG shots are out of your system and the hCG from the embryo takes over. Then, they’re able to detect pregnancy with accurate levels.

IVF hCG Levels

There is no set level for what beta-hCG levels should be for all patients. Even though there is a certain threshold doctors might use, different patients can have different beta-hCG levels and still be pregnant. 

Beta-hCG levels will be different among patients who used hCG during stimulation versus those who didn’t; those who got a fresh or frozen transfer; those who had a single or multiple embryos transferred; etc. But generally, having a beta-hCG level over 100 is considered a good sign for a potential clinical pregnancy.

  • In a study, beta-hCG levels over 100 had a clinical pregnancy rate of 60%. 
  • Beta-hCG levels below 100 were associated with biochemical and ectopic pregnancies.
  • Patients with beta-hCG levels below 200 have a 40% chance of biochemical pregnancy, so it’s advised they are monitored closely.
  • Beta-hCG levels above 600 indicated a triplet pregnancy. [1]
  • In another study, beta-hCG levels over 386 resulted in a live birth 91% of the time. [2]

What is more important than the level itself is how it progresses. 

  • Beta-hCG levels should double up every 48 hours. This indicates a successful pregnancy.
  • If beta-hCG levels drop, it indicates a biochemical pregnancy or miscarriage.
  • Higher beta-hCG levels can predict twin and triplet pregnancies, and this needs to be confirmed with an ultrasound.
  • If your beta-hCG levels are going up, but very slowly, it can indicate an ectopic pregnancy.

Beta-hCG levels for people who went through fresh vs. frozen transfer will also differ. 

With fresh transfers, hCG levels will rise because of ovarian stimulation, or the trigger shot, and it will remain in the system for a while. So, before a pregnancy test can be performed, it should be discarded from the system. 2 weeks after the transfer, it should be okay to perform a pregnancy test and get an accurate result. So if there is a pregnancy, hCG levels during fresh cycle IVF should rise, fall, and rise again. hCG levels after IVF frozen transfer will go up from 0 because frozen transfers do not require prior stimulation with gonadotropins.

IVF Failure

IVF failure is the worst outcome of any cycle. The cases where we deem IVF unsuccessful would be implantation failure, chemical and ectopic pregnancies, and early miscarriage. While doctors and science at large are doing their best to prevent negative outcomes, as it is today, IVF is unable to guarantee a 100% success rate. A failed IVF cycle is a reality, and patients should be prepared for it by being informed of their circumstances and realistic chances of success.

Why does IVF fail?

After transfer, there might be various reasons why a cycle can fail. While doctors take every measure necessary to prevent a failed cycle, they are not able to prevent or fix what happens after transfer. 

  • The egg and sperm used to make the embryo were not of good quality to begin with. 
  • The embryo has a chromosomal or genetic abnormality.
  • The embryo wasn’t able to hatch and implant.
  • The uterine lining wasn’t receptive enough for the embryo.
  • Lifestyle factors such as diet, exercise intensity or frequency, or substance use can negatively affect the treatment at every step, including what happens after transfer.
  • Immunological problems can cause implantation failure by attacking the embryo.

After a failed IVF transfer, the various reasons mentioned above can be examined in detail, and the information can lead to a more successful cycle next time.

What causes implantation failure?

There are various causes of implantation failure. Implantation is one of the actual “natural” processes that occur during IVF. After transfer, there isn’t much that doctors and patients can do to prevent implantation failure. All measures taken are either preventative or what is learned from the failed cycle informs the decisions made on the next cycle.

  • The uterine lining is too thin to support an embryo.
  • The blastocyst had good morphology but had genetic anomalies.
  • The patient has anatomical or hormonal problems that prevent the embryo from implanting.
  • The immune system sees the embryo as a foreign object and doesn’t let it implant. 

In some cases, it’s not possible to determine the cause of implantation failure.

How can you prevent implantation failure?

There are stories of various home treatments, dietary supplements, or foods you can take to improve implantation failure that have no scientific data backing them. Instead, we will provide you with actual steps you can take with your doctor so you can improve your chances of implantation.

  • If you haven’t changed your lifestyle to be healthier, start now. This will improve egg and sperm quality and result in higher-quality embryos.
  • Ask your doctor to use Preimplantation Genetic Testing to see which embryos are of higher quality and thus have a better chance of implantation.
  • Opt for Assisted Hatching to give the embryo the best chance at implanting, especially if you’re going through a frozen cycle.
  • If the problem is with the uterine lining, going for a frozen embryo transfer might be beneficial. With frozen embryos, doctors can optimize the uterine lining to be more receptive.
  • Ask for tests such as ERA, ALICE, and EMMA (also known as EndomeTRIO) to find out about the condition of your uterine lining and to determine at which date your uterus is the most receptive.
  • Ask for immunology tests such as Natural Killer Cell tests to find out if the cause of your infertility is immunological.

Why does IVF fail with good embryos?

What if your embryo was of good quality and passed embryo grading but still failed to implant?

  • The embryo might have genetic anomalies, but we wouldn’t know without performing PGT.

If you performed PGT and still had a good quality embryo that failed to implant,

  • The uterine lining wasn’t thick enough to support an embryo.
  • The patient has anatomical or hormonal problems that interfere with the implantation process.
  • The immune system doesn’t let the embryo implant. 

Again, in some cases, there is no apparent reason for implantation failure.

What happens to the embryo if it doesn't implant?

If the embryo was unable to implant, it will disappear or shed during your period with the uterine lining. Your first period after a failed IVF cycle can seem out of the norm, with too Many blood clots, etc. This is because your uterine lining was most likely very thick to hold a blastocyst, so the clots don’t come from the embryo at all. After transfer, the blastocyst is still very much invisible to the eye, and you won’t be seeing an embryo in your menstrual blood.

Chemical Pregnancy and IVF

A chemical pregnancy, also known as a biochemical pregnancy occurs when there is a very early miscarriage in the pregnancy.

Biochemical pregnancies are like a false positive test in the sense that the pregnancy test is positive but there is no embryo in the ultrasound. With a biochemical pregnancy, hCG levels are detectable in the blood. This means that the embryo was producing hCG. However, since the miscarriage occurs almost right after implantation or because implantation doesn’t occur at all, hCG levels start going down.

Biochemical pregnancy is confirmed by a positive hCG test and no sign of clinical pregnancy such as a gestational sack during the ultrasound. Shortly after a biochemical pregnancy, menstruation begins.

Clinical pregnancies occur mostly due to genetically abnormal embryos and low endometrial receptivity because the uterine lining wasn’t thick enough for the embryo to implant. On top of these reasons, stress and sperm DNA damage are also very common reasons for biochemical pregnancies.

Biochemical pregnancy after IVF is one of the most disappointing of all the possible outcomes of this treatment because the initial positive hCG test can give patients the wrong idea. However, biochemical pregnancies indicate that the embryo was able to implant but lacked the support of an optimal environment, and this means that the person can get pregnant again in the future.

A lot of patients get discouraged from continuing with IVF treatment after a biochemical pregnancy. However, biochemical pregnancies have a bad outcome with a really good prognosis; if the person gets another cycle of IVF, they’re more likely to be successful. [3]

Ectopic Pregnancy and IVF

When everything goes as planned, the embryo should implant itself into the uterine lining. However, sometimes the embryo implants into places it cannot survive. An ectopic pregnancy is when the embryo implants itself somewhere other than the uterine lining. 

Ectopic pregnancies mostly occur in the fallopian tubes; however, it’s possible for embryos to implant outside the uterus, to the cervix, on the ovaries, and even, in some rare cases, on the bowel and the abdomen. The most common causes of ectopic pregnancies are tubal damage and blockage due to previous surgeries, sexually transmitted infections, and smoking.

Ectopic pregnancies can test positive with at-home pregnancy tests, and they need to be confirmed with ultrasound.

As the embryo grows into a fetus, it’s not able to survive anywhere other than the uterus. For this reason, ectopic pregnancies cannot progress and have to be terminated. If ectopic pregnancies are not terminated, they can cause the fallopian tube to rupture,  and can even lead to the death of the mother; 10% of maternal deaths are associated with having an ectopic pregnancy. [4]

Can you have an ectopic pregnancy with IVF?

Yes. Unfortunately, IVF is not able to prevent ectopic pregnancies. There is also a misconception that IVF causes ectopic pregnancies, which is untrue. The chances of ectopic pregnancy with IVF are between 4% and 11% [5], which seems extremely high. However, we must not forget that the number one cause of ectopic pregnancies is tubal factors, and patients with blocked fallopian tubes have to opt for IVF if they want to get pregnant. This can cause the illusion that IVF causes ectopic pregnancies, but it’s actually the tubal factors. If the person has no prior tubal factors affecting their infertility, they have a 2.6% chance of developing an ectopic pregnancy with IVF, which is comparable to the USA national rate of 2% [6] [7].

Signs of Ectopic Pregnancy After IVF

Symptoms of ectopic pregnancies are:

  • Having missed your period and other pregnancy symptoms
  • With ectopic pregnancies, beta-hCG levels double every two days. However, the amount is significantly less compared to healthy pregnancies. So a low beta-hCG level can be an indication of ectopic pregnancy and should be monitored closely. 
  • Ectopic pregnancies can cause abdominal pain and vaginal bleeding.

If left undiscovered and untreated, ectopic pregnancies can cause the fallopian tubes to rupture, which can lead to death if left untreated. Symptoms of a ruptured ectopic pregnancy are:

  • Severe and acute abdominal pain.
  • Vomiting, fainting, dizziness.
  • Pain in the shoulder from 

If you’re having these symptoms, please seek emergency help immediately.

IVF and Miscarriage

Unfortunately, miscarriage is a part of life and pregnancy. Both in natural pregnancies and IVF pregnancies, it’s one of the most devastating results. What’s important for patients to know is that miscarriages are not caused by something that they did; it’s never the mother’s fault. In most cases, miscarriage occurs due to factors that we cannot control or prevent. 

We want patients to know that they’re at no fault for experiencing this loss, and they should take as much time and space to process the situation as possible and grieve. 

What causes early miscarriage in IVF?

Let’s learn more about the causes of early miscarriage during pregnancy.

  • Advanced maternal age is the number one risk factor for miscarriage. Women who are 45 and older can have miscarriage rates as high as 53% [8].
  • Chromosomal and genetic abnormalities are the leading causes of miscarriages in all pregnancies. Around 50% of all early pregnancy losses are due to chromosomal abnormalities. [9]. Chromosomal abnormalities are preventable via PGT.
  • Luteal support is extremely important to maintain a pregnancy. Going off progesterone before your doctor tells you to can lead to miscarriage.
  • Problems with the placenta can prevent the proper development of the fetus by either not attaching to the uterus the way it’s supposed to or not being able to prevent infections from getting to it.
  • Uterine anomalies can especially cause recurrent pregnancy loss. It’s possible to diagnose uterine anomalies with a hysteroscopy.
  • Cervical insufficiency can induce miscarriage or premature birth because the cervix is not able to support the fetus. 
  • Immune factors can cause miscarriage by attacking the fetus, which is seen as a foreign object.
  • Infections from STIs or other causes like food poisoning can lead to miscarriage.
  • Medical history is also an important aspect. If you have unmanaged diabetes, blood pressure problems, or thyroid problems, you’re more likely to have a miscarriage.

Signs of Miscarriage After IVF Transfer

Miscarriages require immediate medical attention, and if you’re experiencing the symptoms below, you should seek emergency medical help.

  • Bleeding that starts light and turns heavy is the telltale sign of a miscarriage. What can start as spotting will turn into a very heavy flow that is difficult to manage. Bleeding requires medical attention as the flow can change from light to heavy to hemorrhaging. 
  • Passing blood clots and tissue is also likely during a miscarriage if you’re later in the pregnancy. It’s possible to pass large blood clots and tissue and experience labor-like symptoms. 
  • Severe cramping and pain in the pelvic region are expected during a miscarriage.
  • Weakness and nausea are usually early symptoms of a miscarriage.
  • Having a fever during a miscarriage is a sign that there is an infection going on, mostly due to the miscarriage itself.

In some cases, a miscarriage can be managed at home, under a doctor’s orders, of course. However, in some cases, some people might have difficulty completing the process and may require surgical treatment to do so, like a D&C.

Grieving After IVF Failure

So, your cycle did not result in a live birth, a viable pregnancy, or you had a miscarriage. Now what? Some people choose to go on another cycle as soon as possible. Some need to wait months, or even years, before they gather the courage to try again. Everyone grieves in their own way. 

It’s a given that negative outcomes of IVF put patients in severe distress [10], and can lead to newly developing or worsening mental problems. For this reason, patients must take some time to grieve, heal, and recover.

  • Professional counseling can help so much throughout the grieving process. We strongly recommend patients seek professional mental health guidance throughout the IVF process, especially after a negative outcome.
  • Have a support system of friends and family that can help you and put a smile on your face through this hard process. Go out, have heart-to-heart conversations, and do activities together to remember that you are not alone.
  • Talk to your partner about your experience, your feelings, and your plans for the future. People who went through failed cycles are more likely to think that their relationship with their partner was negatively affected. Instead of growing apart, you can choose to grow stronger with your partner by building healthy communication.

Give yourself grace and time, as grief comes in waves. Do not blame, or get mad at yourself for anything. Grief is different for everyone, and it doesn’t matter what it looks like as long as you’re trying your best to take good care of yourself. Take as much time as you need to process everything, and do not rush to make any decisions.

What are my options after failed IVF?

After you give yourself some time to heal, you might want to start to think about what you want to do after this cycle. Below are some possible options.

  • You can get another round of IVF and use adjunct treatments that will increase your chances, such as PGT or the ERA test. You should discuss with your doctor what could have caused things to go wrong in the last cycle and what you can do in the subsequent cycle to eliminate the chances of it happening again. Keep in mind that you need to wait 1-2 months in between cycles.   
  • You may consider using donor gametes or a donor embryo if your cycles fail due to egg, sperm, or embryo quality.
  • You may consider surrogacy if you are having recurrent implantation failures and miscarriages.
  • You may consider adoption to become a parent.
  • You may choose to cease fertility treatments for now, or permanently, and consider a child-free lifestyle.

In the next chapter, we will look into and answer questions about IVF pregnancies and IVF babies.

References:

[1] [2] [3] [4] [5] [6] [7] [8] [9] [10]

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