Wednesday, 31 July 2013

Implantation Bleeding after Embryo Transfer

Embryo transfer is the most critical step in the IVF procedure. 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. Pregnancy rates can vary by Physicians, and this is all because of transfer technique. Once the disparities between transfer techniques were corrected and integrated, 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. So, if you were paying much more money for an IVF cycle, would ask for a more experienced doctor to do the transfer.

After we discharge our patients from implantation unit, we send them home with instructions to go about the rest of the day and ensuing two weeks with normal, reduced activity. There is no need to be on bed rest. All our patients have different medication protocols that they go home with. Often referred to as the two week wait so we have now come to the end of the IVF procedure and the maximum that our technology can help a person to achieve a pregnancy. We are at the point where we have to wait and see. If a day-3 transfer was done, it will take approximately 7 days for the remainder of the process to be completed and for the pregnancy test to be positive. For that reason, it is refer to pregnancy tests at 8 or 9 days post transfer. For a blastocyst transfer, you only need three more days to get a positive pregnancy test.

Pregnancy occurs when the egg is released by the ovaries, fertilized by sperm to form a Zygote fertilized eggs. This process occurs in the fallopian tubes, the Zygote travels to the uterus and during this period, it was further divided to form a blastocyst, which can be described as a ball of cells with sheath. Once the blastocyst reaches the uterus, it gets out from the protective outer layer and glued on the inside lining of the uterus (endometrium). Through this entanglement, blastocyst formed a relationship with the mother's blood vessels, to receive the oxygen and nutrients needed for growth.The blastocyst can cause a slight amount of bleeding, such as penetrating the endometrium and will be attached to the uterus. This blood coming out from the uterus through the vagina, and this incident is called implantation bleeding, which is considered as one of the signs of early pregnancy. Although it is a sign of pregnancy, absence does not mean that there is no pregnancy, no. In other words, every pregnant woman is not likely to experience bleeding, because it is not necessary to cause bleeding while the blastocyst implanting itself in the uterine wall. It is said that only a third of women experience this condition. The basic idea about the signs and symptoms of implantation bleeding and the time of the occurrence may be useful in recognizing the condition.

This usually happens right before the estimated date of the menses. The average menstrual date is calculated as the 14 day from the date of ovulation (the cycle can vary between women) and the implantation bleeding occurs between six to twelve days after ovulation. In other words, this bleeding usually occurs on the third or fourth week of the date of the last menstrual period. Eggs that have been fertilized or Zygote takes approximately five to six days to travel from the fallopian tubes toward the uterus. After that, it will be attached to the endometrium. Thus, implantation bleeding is said to occur in nine to twelve days of ovulation. But in some cases, it may occur as early as six days as well. So, the time frame for the occurrence of implantation bleeding is usually given as 6 to 12 days after ovulation. Even the time taken by the blood to come out of the womb may affect the time of implantation bleeding.

As mentioned above, this type of bleeding is caused by small amounts of blood that is released from the blastocyst attachment locations on the endometrium. First of all, you must understand that implantation bleeding is not likely to occur in women. It may happen that the endometrium does not bleed at all, while the blastocyst will be attached. Even the amount of bleeding can vary from one woman to another. So, the first and foremost sign of bleeding implantation bleed itself. The vaginal discharge may be too minimal or spotty in some women, whereas in some others may be a little heavier. However, in this case the type of bleeding, blood will be pink or Brown, like old blood (it takes some time for the blood to come out of the womb). Commonly, implantation bleeding is not associated with any symptoms, but some women may experience minor cramps in uterus and increased basal body temperature (the lowest temperature attained by the body during rest, usually while a sleep).In addition to the implantation bleeding and other symptoms of pregnancy include nausea or vomiting, tender and swollen breasts, frequent urination, fatigue, flatulence and increased sensitivity to odors. If these symptoms develop after implantation bleeding along with the late period; they may indicate pregnancy. However, confirmation of the pregnancy is done with a blood test and urine as well as obstetrical ultrasound. If implantation bleeding is accompanied by pain, you should consult with your obstetrician.

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 a traumatically 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 these cause bleeding. 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, 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. 

For some patients, because used both vaginal and injectable progesterone by the experts, 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 occurring 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. Patients not to worry about this; the only bleeding that patient 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.

The body is a fluid and dynamic structure and there will be many sensations that patients report during this period. Some will report many types of “pains”, some will have “cramping” and some will have “bleeding”. Most of these symptoms are not of any consequence but cause patients to needlessly worry. Some doctors have referred to these “pains or cramping” as implantation related. That may be the case but no one knows for sure. Certainly with implantation, the uterus is undergoing changes and cramping tends to be one way that uteri react. So, if the timing is appropriate, namely at the point where implantation would be expected as described above, then these sensations could certainly be related to it. Of course, onset of one’s period can also be signed by cramping but this is usually accompanied by bleeding. If adequate hormone replacement is given in the luteal phase of the process, then the period should not start until the medications are stopped. That is the cause of the onset of the bleeding and cramping associated with a period; it is the withdrawal or abrupt drop in hormone levels. Some will claim that this is the uterus “stretching or growing” but this could not be the case at this point in the pregnancy. 

The embryo is like a mere fleck of dust within the cavity and not big enough for the uterus to begin “growing.”Some patients will experience sharp or stabbing pains, on the other hand, that may not be from implantation but more from the ovaries. About three days after the retrieval, the ovaries will refill with fluid and this stretching of the follicles and ovaries certainly can cause pain in one side or both sides. This is the pain sensation that most patients have during this period of time. Post IVF complications causing severe pain include Ovarian Hyper stimulation Syndrome (OHSS), ovarian torsion (twisting), ovarian flow of blood, Ectopic pregnancy and Pelvic infection. 

If the pain is mild, then intervention is probably not required but if severe, it could be one of these serious medical problems that will require medical treatment because they could be life threatening. You should know, however, that these complications are very rare. On the other hand, if you have had a positive pregnancy test and these symptoms occur impending miscarriage could be another source of cramping or pain.Bleeding within this period of time is also a very common complaint. In most cases this bleeding is inconsequential but it could also indicate problems such as inadequate hormone support for the Luteal phase, thereby causing the endometrial lining to start to slough. 

It could also indicate that the period is starting or that an abnormal pregnancy exists or is being miscarried. When the bleeding is light, I usually will reassure my patients that no intervention is required. For one, there is no intervention that can be done, other than checking hormone levels and increasing the progesterone if the level is inadequate. Secondly, this could be normal, if in fact it is implantation bleeding. Thirdly, if vaginal progesterone is used, the progesterone may be causing the cervix to be more delicate or friable and therefore cause cervical bleeding. If implantation bleeding is accompanied by pain or heavy bleeding, you should consult with your obstetrician.


  1. I had my first IVF cycle in Nov 13. That time I experienced cramps and spotting of 4 or 5th day after ET. also, I experience heaviness in lower abdomen and frequent urination. I suppose i had implantation but did not turn into pregnancy.

    This time I am on my 5th day after ET but do not experince cramps or spotting or heaviness or frequent urination. Does this mean ther is no implantation at ll? Are there still chances of implantation and pregnancy for me?

    1. It the great post and all about pregnancy. Will of course be helpful for the expecting ladies and their family. I am happy with getting this post as I am expecting on next June. Thank you for this nice post.

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  4. I had my second ivf cycle in November 4 and today I was saw a light red bleeding I am very worried please help me

  5. I am on my 12 th day of ivf cycle and i had spotting in the morning that was brown and noe i have red spotting i contacted my doctor she told to take duphaton tablets 3 times is it dangeours or negative.

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  9. hello doc please see this link from me - raj uvaraj -
    How long does implantation bleeding last? please update the comment there!

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