Management of Ill-Defined Endometrial-Myometrial Junction in Donor Egg IVF
Proceed with donor egg IVF transfer using single embryo transfer (eSET) of a blastocyst, as the ill-defined EMJ finding on day 3 does not contraindicate transfer and donor egg cycles have excellent prognosis that should not be compromised by transferring two embryos.
Transfer Strategy for Donor Egg IVF
Single embryo transfer is strongly recommended for all donor egg IVF cycles regardless of any prognostic factors, including the ill-defined EMJ finding. 1 The 2024 ESHRE guidelines explicitly state that double embryo transfer (DET) should be avoided at all costs for treatments with donor oocytes because of clearly increased pregnancy complication risks, and instead eSET is strongly recommended for these cases. 1
- Transfer only blastocyst-stage embryos as single embryo transfer due to the higher monozygotic twin potential of blastocysts and the high risk of multiple pregnancy complications after transfer of two blastocysts. 1
- The history of biochemical pregnancy does not change this recommendation, as there is no clear indication in any single factor to favor DET over eSET. 1
- Even with previous failed treatments, DET is not associated with higher cumulative live birth rates in any patient population. 1, 2
Addressing the Ill-Defined EMJ Finding
The ill-defined EMJ on day 3 ultrasound requires consideration but does not preclude successful embryo transfer:
- Ultrasound parameters provide information on endometrial receptivity, but robust evidence for their predictive value is lacking. 1 The role of ultrasound assessment in predicting IVF outcomes needs further study in randomized trials. 1
- Endometrial thickness is an important factor predicting endometrial receptivity, though the specific finding of ill-defined EMJ has limited evidence regarding its impact on donor egg IVF outcomes. 1
Optimizing Endometrial Preparation
- Consider endometrial receptivity analysis (ERA) if this cycle fails, as approximately 36.5% of patients undergoing IVF have a displaced implantation window, and personalized embryo transfer timing achieved 69.2% clinical pregnancy rates in initially non-receptive patients. 3
- The ill-defined EMJ may represent delayed endometrial maturation or structural abnormalities that could affect receptivity. 4
- Hysteroscopy can be considered to evaluate for structural abnormalities if the cycle is unsuccessful, though this should not delay the current transfer attempt. 4
Low AMH Context
Your low AMH levels are relevant for counseling but do not change the transfer approach:
- Low AMH is associated with slightly higher miscarriage risk (particularly when AMH <0.7 ng/ml), though the mechanism remains unclear and may relate to increased embryo aneuploidy rates rather than endometrial factors. 1
- In donor egg cycles, this concern is mitigated because the oocyte quality comes from the donor, not from your ovarian reserve. 1
- AMH levels on the day of transfer correlate with reproductive outcome in autologous cycles, but this is less relevant when using donor eggs. 5
Critical Counseling Points
Patients must understand that transferring two embryos increases risks without improving cumulative live birth rates:
- Risk of ectopic pregnancy increases up to 20-fold with transfer of more than one embryo. 1
- Multiple pregnancy complications include pre-eclampsia, gestational diabetes, emergency cesarean section, and preterm labor. 1
- Even singleton pregnancies after DET carry higher risks of neonatal death and complications compared to eSET. 1
Monitoring and Follow-Up
- Use serial β-hCG monitoring combined with ultrasound surveillance to rule out ectopic pregnancy until either an intrauterine pregnancy is confirmed or β-hCG declines to <5 mIU/mL. 6
- If this cycle results in biochemical pregnancy again, maintain the single embryo transfer approach for subsequent attempts, as previous failed treatments do not justify DET. 6, 2