The IVF Missing Piece: Why Recurrent Miscarriage May Not Be “Just Egg Quality”

0:00Recurring miscarriage, 5 % of the pregnancy, no matter is natural, insemination or fertilization. The 5 % is the chromosome of the genetic healthy of the embryo and the rest is a house. So what's going on in the house? It's so much easier in a 20-something to start to course correct hormones than it is in the 30-something and especially as we get older and nearer to perimenopause. Dr. Gerardo Barroso Villa is a world-renowned fertility expert and reproductive biologist Trained at prestigious institutions like the Jones Institute for Reproductive Medicine and Cornell University, Dr. Barroso has over 2 ,500 international citations for his research and serves as an ad hoc reviewer for leading medical journals.

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1:16It specifically works after unprotected sex and before pregnancy occurs by temporarily delaying ovulation. Plan B is available nationwide at all major retailers and through delivery apps like DoorDash. No ID, prescription or age requirement. It's the number one OBGYN recommended brand of emergency contraception and it won't impact your future fertility. That's freedom to be. Use as directed. I always explain recurrent miscarriage in you have a box and the box is divided in two. 85 % of the pregnancy, no matter is natural, insemination or in vitro fertility shape, the 5 % is the chromosomal, the genetic healthy of the embryo.

2:01And the rest is a house. So what's going on in the house? Most of the time, the doctor says, by definition, you have to lose at least two pregnancies before you start looking for the problem. And I say, why? Well, we have to do that. Even if you have the first miscarriage, take the tissue, make the chromosomal analysis, and see if everything was as expected. Some genetic abnormality means Down syndrome. If it's not, where's the problem? We have to look at the house. We have to see if you have any scars into the uterus. Most of the time in the United States, they have a previous miscarriage or you have to use some curative.

2:53So create some scars into the endometrium. And you can't see that. It's nothing you can see that. Or you have some blood disease like thrombophilia. So we have to be in the correct size to look into the house or into the embryos. When in our population, thrombophilia is a real issue. We look for the three factors related with the thrombophilia. Even though if you got pregnant and you have thrombophilia, you have the risk for prematurity or preeclampsia or other placental disorders. So when we use the correct therapeutic tool, we have the chances to correct them, to get forward in the pregnancy, to get a healthy baby.

4:03So I think this is a great time to talk about endometritis because this can be a big contributing factor to recurrent pregnancy loss. If you say, well, I check my vaginal cultures and everything is fine. Yeah, but it's not. For the last 20 years, we believe that the endometrial cavity was sterile. It was not. So we have to find a specific, we perform a specific test to look for those chronic infections. We call the ALICE. So the ALICE has the chance, it's very advanced technique, genetic technique, where we can look into the cavity and find if you have this condition, okay? You have the infection.

4:59And many times we are people who likes to take some antibiotics for everything. For the flu, for the gastroenteritis. Yeah, but everything affects. affects your microbiome. Yes. Your natural microbiome. So we have, we require this balance into the microbiome, into the uterus. The lactobacillus have to be according for the healthy relationship with the embryo. So now we know that we have found that some of the patients, They have a great, beautiful genetic test embryos. They don't get pregnant. They found that they don't have any, or they have an infection also. Yeah. That is, when you repeat all this vaginal examination, we never found something to help us to treat infections and start looking to create the best environment for the embryo.

6:08Well, I love that you bring up that what affects your gut health is going to affect the reproductive microbiome as well. And so people understand the gut microbiome, we want to be very diverse. Diversity is a sign of health. The endometrial microbiome, we want almost no diversity. It needs to be 90 % predominantly lactobacillus species. And so you mentioned the ALICE test. So there's Alice and Emma, those are done by endometrial biopsy. Is there any sign outside of that, that someone would know that possibly they could have endometritis without doing that testing? No, really. There's not. So why is it that we don't see more clinicians doing this testing, making sure that the health of the uterus is optimized, not just the health of the egg?

6:54I feel like when it comes to fertility, there's still so many doctors that reduce everything to just the egg. And I like to say that women are both the seed and the soil. We are going to provide the egg, but sperm matters as well. And we're going to talk about that. But there's also the soil and the soil has to be healthy. The microbiome, as you mentioned before about supplements, your nutrients, the amount of inflammation, all of that can really determine whether that healthy embryo in plants or not. Yeah. I believe it's related with how the doctors are, they think in our organization. Let me explain.

7:34Sometimes it's not a medical issue. You start doing more than 10 years ago PGTA for everyone. Okay, but define what PGTA is so people know. Sorry, PGTA is the test that help us to recognize some chromosome abnormality, some genetic disease. We have about 25 % in our best condition to get pregnant. And the question is why? It's because not of all the eggs or sperm is healthy. When we have the health of the DNA for each one, across all these chromosomes, you get a healthy embryo. For some conditions, you got not, like Down syndrome, plenty further, Turner syndrome. And when I were talking with my team, I say, we're going to perform PGTA.

8:33But the decision is related with information. As much information you get, you can decide. Because infertility is so many variables. You have factors. Yeah. And no one knows if you have to do surgery, laparoscopic, open, or insemination, or you have to try three to six months regular intercourse or insemination or imitrofertilization. Why? You have to decide what is going to be the platform related with the information. So the decision is if you have as much information, you have the power for decision. If I know how is a microbiome, if I know I have that endometritis, a healthy embryo with PGGA, where chances to get pregnant increase dramatically.

9:28Because you say, is the percentage of one population. Yeah. The patient don't want to be in statistics. You're looking for objective. So that's why we have to do. Yes. And that's why I love your approach because it's very data driven. I'm a big fan of trying to gather as much data as possible. And it's very bio-individual. And I feel like so often I run into clinicians who are like, well, this is what the research says and we just stick to that. And it's like, well, you have to interpret it in the context of the individual who's sitting in front of you. We can't just say, well, statistically speaking, this is what's true for somebody who's 35.

10:07I was reading statistics about it. miscarriages be related 20 % of the time to the uterus and 30 to 60 % of the time we've got endometritis going on when there's been this recurrent pregnancy loss. So who would be at risk for endometritis and how do we treat that? How do we restore the microbiome? As I said, if by the time you, and you don't have to be infertile, I have a patient who, She got pregnant. She delivered a baby. It was kind of complicated. And she got an infection after the delivery. She can get pregnant two years after that. And no one can find what was the problem. And we were talking.

10:55I say, yeah, how was your delivery? Was a c-section? Yeah, was a c-section. that I have an infection. I say, did you? Right. I perform Emma analysis. She got a pretty bad infection into the uterus. Just a chronic, not symptoms, not high temperature or something, and not lactobacillus. So we treat the infection and start doing our supplementation. And we treat the infection with the antibiotics so everybody's clear that there is a time and the place for antibiotics. Always, always. When you treat an infection, you have to start with lactobacillus. You have to recover this microbiome because you're going to kill it.

11:45So two months later, she got pregnant spontaneously. Yeah, I love to work with processes. My head is working in process. And in process, we define these KPIs. key performance indicators. In our team, we have all these processes and we have this KPI. I want to hear what these KPIs are. I'm very interested. The first one is how is your variant reserve? Okay. And that was the AMH you mentioned earlier, anti-malarian hormone. Anti-malarian. Did you find that your anti-malarian hormone decrease? Is it time for looking for a pregnancy or free sex? If you are really certain that you're going to be a mom or dad.

12:36Second, always is a sperm. One of the first conditions for infertility is the male factor. We have a study from Fulvajum that they look for sperm in males from 1920 to 1994. and they saw a decrease in under 50 % of concentration and motility. So we have to be sure that we're working with a good, healthy sperm or start doing something. It's not just for looking for the positive pregnancy test because 20 years ago, we do everything just to get pregnant. Now, we're looking not just for the pregnancy, for a healthy baby, because the placenta came from the sperm. So now, in vitro fertilization babies, we know they born early.

13:37They have prematurity. They have diseases related with vascular disease as preeclampsia. And everything is related with the sperm. Yeah. So now we have to look and we are doing not just the regular semen analysis, like the concentration or motility or morphology. We also can evaluate the fragmentation of the DNA and see how healthy or how it's going to impact during the embryo formation. And we have another tools to select the right sperm. We use some, we call PIXI. We use hyaluronic acid to attach the more functional sperm before make the injection through ICSI into the egg. And in ICSI, you choose the sperm under a microscope.

14:36The egg gets to choose the sperm in the natural environment. And in the lab, ICSI is taking the sperm and actually choosing the sperm that will inseminate the egg. Yes, it's correct. And we do ICSI for everything because we know already when something is not working well. It could be a molecular diagnosis because in vitro, okay, you're looking for a treatment. But also it's a diagnostic tool. You can see in every step what is going on. You have to change something during the process. At the end, we perform the AXE because our last outcome has to be to get this healthy PGTA embryo before the embryo transfer.

15:20When you look at sperm, KPIs, DNA fragmentation, what are you looking for? What should people know that if their doctor has run some of these tests that, you know, if you've got these parameters, we need to intervene? If you have below 15 million of sperm, more time, you can have 15 million. You just move 10%. Before that, we have to start thinking about insemination or even metofertilization. But also, the question is, which one is better? because in the school, everyone thought that you have to escalate like stairs. You try naturally and then we're going to give you a pill, the chlamide, or and then we're going to start applying some injections.

16:16And after that, we're going to do insemination. Today, you still have unexplained infertility. For me, it's not unexplained. This is because you're not looking. You have unexplained infertility. You have your 20%. But today with imitofertilization, we can reach over 70 % chances to get pregnant. Because when you start with this third process to reach after five years IVF, you lose any chances for your ovarian reserve. The best chance for in vitro fertilization is when you have a really good number of eggs, good quality, you're young, and you have the best of you for in vitro fertilization. That's why always you have to decide which one is the best way for you.

17:14And it has, it's not has to be just for the medical.