Breakthrough Bleeding Following Missed Doses of Estradiol Valerate in a Surrogate Undergoing Endometrial Preparation 8 Days Prior to Embryo Transfer: A Case Report

Background: Endometrial preparation is an important step in the in vitro fertilization procedure. It involves the use of estradiol valerate. Once endometrial preparation has commenced, there should be no bleeding and the endometrial thickness should be between 7 mm and 12 mm for optimal embryo implantation. Case Presentation: A 24-year-old P 1 + 0 petty trader presented to St Elizabeth Hospital and Fertility Centre Limited, Enugu for surrogacy. She subsequently commenced the IVF procedure and during the endometrial preparation, she missed three doses of estradiol valerate. Following this, she started bleeding 8 days before embryo transfer. She was re-evaluated and was given a stat dose of leuprolide acetate 3.75 mg and the dose of estradiol valerate was increased as well. The bleeding stopped. Following embryo transfer, pregnancy was confirmed two weeks later. Pregnancy was uneventful until 11 weeks + 5 days when she had a threatened miscarriage which was managed and she got well. She had antenatal steroids at 30 weeks of gestation and delivered via elective caesarean section at 37 weeks + 2 days of gestation with a good feto-maternal outcome. Conclusion: Breakthrough bleeding before embryo transfer affects endometrial thickness which also affects implantation. A cycle that was complicated by breakthrough bleeding was successfully salvaged with a specific intervention leading to a live child.