Bleeding After Embryo Transfer

In the course of my volunteering as the Infertility Expert on About.com's AllExperts site, as well as here on my own blog, I have had many questions regarding bleeding right after embryo transfer or in the Luteal phase. What follows is an attempt to answer one of the chief concerns that IVF patients have, namely, "What if I have bleeding after my embryo transfer?" 

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Answer:

The embryo transfer is the most crucial step in the In Vitro Fertilization procedure/process. You can have the best quality embryos, but if they are not placed into the uterus correctly, then pregnancy will not occur. That is why "transfer technique" is so important. There have been studies showing that pregnancy rates can vary by Physicians within the same group, and this is all because of transfer technique. Once the disparities between transfer techniques were corrected and unified, the pregnancy rates became consistent. For this reason, you want to seek out a Physician who has a lot of experience with embryos transfers and comparable good pregnancy rates. If you go to a clinic that has multiple doctors, ask for the pregnancy rates of each Physician or your particular Physician. Although I know that newly trained REI Physicians have to get experience, most don't have a lot of embryo transfer experience from their fellowship. So, if I were paying $10,000 or more for an IVF cycle, I would ask for a more experienced doc to do the transfer. For more details regarding post embryo transfer bleeding, pain and other symptoms, see "What To Expect After Your Embryo Transfer". 

Bleeding, usually bright red blood, with the embryo transfer is an absolute no no. If blood contaminates the endometrial cavity at the time of the transfer, this will kill the embryos and pregnancy will not occur. The catheter must be placed as gently and atraumatically as possible. That is an absolute requirement. The endometrium, which is now in its fullest growth state, thickened from estrogen stimulation, can be easily scraped and cause bleeding.  

At our center, we use very soft catheters, very gentle technique, ultrasound guidance and mock embryo transfers preceding the cycle, to accomplish this. The mock embryo transfer or MET is especially important so that the Physician is not learning the curves of your canal at the time of transfer but has worked it out prior. You should have the same Physician who did the MET doing your transfer. This is especially important in patients whom we consider to have a "tortuous" canal, making it more difficult to insert the catheter with care. In this type of patient I will sometimes do the MET two to three times to become well acquainted with their canal.  

You should not worry if brown blood or discharge occurs at the time of transfer, it will usually manifest within the first day or so after the transfer, but not into the mid-luteal phase or later. That type of bleeding would be from a different source.  

There are situations, however, when bleeding can occur but not be ominous. Sometimes a woman's cervix will bleed easily from being scraped by the speculum or irrigation or wiping. This external bleeding will not affect the endometrial cavity as long as the transfer catheter is not exposed to the blood. For example, I do not let the catheter get exposed until the introducer is well into the cervical canal, near the internal cervical os (entrance to the endometrial cavity), to begin advancing the catheter.

Bleeding that occurs later in the luteal phase, days after the transfer, is very common if vaginal progesterone is used. This has been shown in various studies using Crinone, for example. In my patients, because I use both vaginal and injectable progesterone, it is almost 90%, but the bleeding tends to occur near the time of the pregnancy test or soon thereafter. This is probably caused by some erosion occuring on the external cervix. The exact cause, however, is not clearly understood. It is usually light spotting and can be anywhere from red to brown. Red is newer blood and brown is old blood. In general I tell my patients not to worry about this. The only bleeding that I would worry about is bleeding that is red and heavy like a period. This is not good, and should not occur if the hormones progesterone and/or estrogen have not been discontinued. Some patients will experience slight spotting 3-5 days after embryo transfer and refer to this as "implantation bleeding." Whether or not this is caused by implantation is not known. Implantation should not cause bleeding. However, again, if it is not bright red blood that is heavy like a period, it should not cause worry.  

I certainly hope this information will help those of you who have either queried me or who have Googled for some reassurance in this regard.    

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
http://www.montereybayivf.com/