Transcript Failed IVF Cycles: What to do? - William Schoolcraft, MD, HCLD

Recurrent
Implantation Failure
Sharkey, RBMonline, 2013
Copyright © 2013 Reproductive Healthcare Ltd. Terms and Conditions
Figure 1
Early implantation failure -during the
attachment or migration
stages(negative blood pregnancy test.
Late implantation failure- following
successful migration of the embryo
through the luminal
surface of the endometrium, but the
process becomes
disrupted prior to the formation of an
intrauterine gestational sac.
(biochemical pregnancy).
Source:
Reproductive BioMedicine Online 2014; 28:14-38 (DOI:10.1016/j.rbmo.2013.08.011 )
Copyright © 2014
 (Tan et al., 2005): Failure to achieve a pregnancy
following 2–6 IVF cycles, in which more than 10 highgrade embryos were transferred to the uterus was
defined by various clinicians as RIF.
 In the era of limited embryos transfer, there is no
consensus.
 Propose: RIF be defined as the failure to achieve a
clinical pregnancy after transfer of at least 4 good-quality
embryos in a minimum of three fresh or frozen cycles in
a woman under the age of 40(Coughlan, 2014).
Uterine Causes of RIF
 Uterine Receptivity




Fibroids
Uterine anomalies
Thin endometrium(asherman’s syndrome)
Altered expression of adhesion molecules, transcriptome,
proteome
 Immune factors, thromophillias
Decreased endometrial
receptivity
 Undiagnosed uterine pathology: In 18–27% of women with a normal initial
hysteroscopy or hysterosalpingogram, repeated hysteroscopic visualization
after RIF revealed uterine abnormalities, mainly hyperplasia, polyps,
endometritis, synechiae and leiomyomata (Demirol and Gurgan, 2004).
 The effect of leiomyomata on implantation is uncertain (Surrey, 2003). The
impact of intramural lesions without cavity distortion (Eldar-Geva et al., 1998)
or myomas of <4 cm (Oliveira et al., 2004) on RIF remain controversial.
 The presence of a thin endometrium did not influence the cumulative PRs in a
prospective large cohort studies (De Geyter et al., 2000), particularly when
high-quality embryos were transferred (Zhang et al., 2005).
 Thin or hyperechogenic endometrium or persistent endometrial fluid impaired the
outcome in tubal factor, but not in polycystic ovary syndrome (PCOS) (Akman et al.,
2005) or ICSI (Rinaldi et al., 1996). However, the concept that a minimum thickness
(4–8 mm) is required to establish a clinical pregnancy is still arguable and should be
considered in RIF.
Pregnancy rate and implantation rate following IVF for controls
without fibroids and subjects with fibroids stratified by their uterine position.
∗P<.05 for IM vs. controls or SS; ∗∗P<.005 for IM vs. controls.
Eldar-Geva T, Effect of intramural, subserosal, and submucosal uterine fibroids on the
outcome of assisted reproductive technology treatment. Fertil Steril. 1998;70:687–691
The impact of intramural
leiomyomata on IVF outcome
Surrey, Fertility and Sterility, April 2000
Intramural myoma
No myoma
Age
36.1
36.8
Pregnancy Rate
55
65
Implantation
23
37*
* <.05
Forest plot of studies of non-cavity-distorting intramural
fibroids versus no fibroids in women undergoing IVF
treatment for outcome of live birth rates.
Aa
Congenital Uterine Anomalies
 Septate uterus may contribute to RIF-untreated septate uteri
had a poor outcome following IVF treatment in comparison
to women who had undergone hysteroscopic metroplasty
prior to IVF (Lavergne et al., 1996). Ban-Frangez et al.
(2009) showed that the presence of a septum, whether large
or small, was associated with a miscarriage rate of about
80%, which was reduced to 30% or so after surgical removal
of the septum
 Bicornuate uteri, a relatively common anomaly and most
women have no difficulty conceiving (Grimbizis et al., 2001).
The main risk for the woman with a bicornuate uterus is midtrimester pregnancy loss and preterm birth (Grimbizis et al.,
2001).
Endometrial Markers
 Lack of integrin –αVβ3 in the endometrium at the time
of implantation was suggested as a cause of
implantation failure (Tei et al., 2003; Thomas et al.,
2003).
 High levels of aromatase p450 mRNA (Brosens et al.,
2004), changes in pinopode expression (Pantos et al.,
2004) and high levels of matrix metalloproteinases
(Inagaki et al., 2003) have been suggested to be
associated with RIF.
Use of microarray technology to compare endometrial gene expression profiles at
the window of implantation according to the levels of circulating progesterone
Gene clustering by Pearson's correlation.
Labarta E et al. Hum. Reprod. 2011;26:1813-1825
 Identified 140 genes significantly dysregulated (64 upand 76 down-regulated) in the high P(>1.5). These
genes are related to cell adhesion, developmental
processes, the immune system and others, which are
all required for normal endometrial function
development.
 CONCLUSIONS Our results reveal that elevated
progesterone levels on the day of rhCG administration
can induce significant alterations in the gene
expression profile of the endometrium.
Venn diagram of transcripts up-regulated and down-regulated during endometrial receptivity
in the natural cycle compared with the stimulated cycle.
Haouzi D et al. Hum. Reprod. 2009;24:1436-1445
The transcriptomic pattern of endometrial cells in natural
and stimulated cycles in the same patients reveals either
moderate or strong alterations of endometrial receptivity
under COS protocols.
A strongly altered profile during COS protocols could
explain multiple implantation failures, and suggest the use
of FET during a natural cycle.
Ultrasound diagnosed adenomyosis has a negative impact on
successful implantation following GnRH antagonist IVF treatment
Thslluri, Hum. Reprod. (2012) 27 (12): 3487-3492.
Hydrosalpinx
 Patients with hydrosalpinges have lower implantation
and PRs (Zeyneloglu et al., 1998).
 Hydrosalpinx fluid is commonly slightly alkaline and
may contain cytokines, prostaglandins or other
inflammatory compounds.
 These compounds may have either direct embryotoxicity or adversely affect the endometrium (Meyer et
al., 1997). Reflux of hydrosalpinx fluid into the uterine
cavity may result in diminishing embryonic endometrial
apposition.
Salpingectomy of
hydrosalpinges
 Strandell and co-investigators were the first to show in
an RCT that salpingectomy of hydrosalpinges
increased PR (Strandell et al., 1999).
 In a recent meta-analysis (Johnson et al., 2004) of
three RCTs involving prophylactic salpingectomy in 295
patients with hydrosalpinges, the pregnancy and live
birth rates doubled following prophylactic
salpingectomy.
 Laparoscopic salpingectomy is now recommended in
all women with hydrosalpinx before IVF treatment,
certainly following RIF.
Copyright © 2012 American Society for Reproductive Medicine Terms and Conditions
Figure 1
Recurrent IVF failure: other factors
IMPACT OF OBESITY
Penzias, Fertility and Sterility 2012; 97:1033-1038 OI:10.1016/j.fertnstert.2012.03.017 )
Smoking
 Associated with an increased gonadotrophin
requirement for ovarian stimulation, fewer oocytes
retrieved, higher numbers of cancelled cycles, lower
implantation rates and more cycles with failed
fertilization in those undergoing IVF treatment (Sterzik
et al., 1996, Van Voorhis et al., 1996).
 Male partners of women with RIF should also be
advised to abstain from smoking due to its adverse
effect on sperm counts and motility, increase in
abnormal sperm morphology and sperm DNA damage
(Potts et al., 1999).
Oocyte quality
 Suggested by:
 poor response to ovarian stimulation (Ferraretti et al., 2011),




with fewer numbers of oocytes retrieved,
a high proportion of immature oocytes,
reduced fertilization rate and low embryo utilization rate.
Often associated with low antral follicle counts, high FSH and
low anti-Müllerian hormone
Age-related decline in oocyte quality is associated with
increased chromosomal non-disjunction, resulting in aneuploid
embryos, decrease in mitochondrial membrane potential and
increase of mitochondrial DNA damage (Wang et al., 2009).
Abnormal Embryonic
Development
 Chromosomal abnormalities of the male or female partner, such as
translocations, inversions, deletions
 Increased incidence of sperm chromosomal abnormalities in patients with
normal karyotype and RIF was also observed (Rubio et al., 2001).
 The disruption of the normal sequence of chromosome replication and
segregation in early human embryos might be a common cause for RIF.
 Increased zona thickness:
 Associated with lower implantation rates (Cohen et al., 1989).
 Zona hardening, which may be induced by in vitro culture or by in vivo ageing, can
also affect hatching (De Vos and Van Steirteghem, 2000).
 Embryonic Stress:
 Several quality control methods have been suggested for identifying suboptimal
components of a culture system (Gardner et al., 2005).
Assisted Hatching and Removal of Degenerate
Material Significantly Improves Implantation of
Frozen/Thawed Blastocysts
Schlenker, Fertility and Sterility
September 2005
,
Number
Ongoing PR
Implantation
Hatching
54
52
27
No Hatching
58
36
16
NS
<.05
Hum Reprod Update.
2011;17:438
A recent meta-analysis of randomized control trials (five
trials with 761 participants), assisted hatching was
reported to be associated with a significant improvement
in clinical pregnancy when performed in fresh embryos
transferred to women with RIF (relative risk [RR] = 1.73
Human Reproduction & Chromosome Aneuploidy
Aneuploidy, the loss or gain of an entire
chromosome, is the most common
abnormality in human conceptions
Chromosome aneuploidy is the leading
cause of both spontaneous miscarriages
and congenital birth defects
Aneuploid embryos that are transferred
will either fail to implant, result in
pregnancy loss or an affected infant
Trisomy 21
Fetus
Meeting the Requirements
of the Embryo
Gardner (1998) Theriogenology, 49: 83-102
mM
mM
0.32
Pyruvate
0.10
10.5
Lactate
5.87
0.5
Glucose
3.15
Gardner et al. (1996) Fertil. Steril., 65: 349-53.
Changing Physiology of the Embryo During
the Preimplantation Period
4 0
3 0
Glucose
2 0
Pyruvate
1 0
0
Zygote
Pyruvate
2-cell
8-cell
M orula
Glucos e
B las tocys t
Role of Amino Acids in
Embryo Development
•
•
•
•
•
•
•
biosynthetic precursors
energy substrates
regulators of energy metabolism
pHi buffers
osmolytes
antioxidants
chelators
Role of Amino Acids in
Embryo Development
•
•
•
•
•
•
•
biosynthetic precursors
energy substrates
regulators of energy metabolism
pHi buffers
Amino acids minimize the
osmolytes
stress within the embryo by
antioxidants
facilitating cell function and
chelators
maintaining homeostasis
Oxygen
• Atmospheric concentration is ~ 20%
• Physiological concentration is ~ 5%
Clinical Data on the Effects of
Oxygen
Meintjes M et al. (2009)A controlled randomized trial
evaluating the effect of lowered incubator oxygen tension
on live births in a predominantly blastocyst transfer
program. Fertil Steril 24: 300-7
Nanassy L et al., (2009) Comparison of 5% and ambient
oxygen during days 3-5 of in vitro culture of human
embryos. Fertil Steril
Sensitivity of the mouse embryo assay (MEA) is
significantly increased by in vitro maturation
Paik, Schoolcraft, Krisher, Fertility and Sterility, September 2013
 IVM embryos are more sensitive to culture media
contaminants than zygotes. Use of an outbred strain
further increases this sensitivity. Determination of cell
number can improve one-cell MEA sensitivity.
 The IVM MEA provides a significantly more sensitive
method of detecting toxins, thus preventing harmful
materials from entering the human ART laboratory.
Other Etiologies of RIF
 Karyotype abnormalities: 15.4% abnormal in patients with
RIF1
 Male factor
 Sperm DNA damage
 advanced paternal age
 Quality of embryo transfer
1Raziel,
September 2002 Fertility and Sterility Vol. 78, Issue 3, Pages 515-519
Extent of nuclear DNA damage in ejaculated spermatozoa impacts on
blastocyst development after in vitro fertilization
Emre Seli, M.D., David K Gardner, Ph.D., William B Schoolcraft, M.D., Odette Moffatt, Ph.D. and Denny Sakkas, Ph.D.
Fertility and Sterility
(August 2004)
Copyright © 2004 American Society for Reproductive Medicine Terms and Conditions
Correlation between percentage blastocyst development
and TUNEL positivity in the spermatozoa
Seli, Fertil Steril 2004
Development to the blastocyst stage of patients
assessed for low (<20%) and high (>20%) TUNEL
positivity.
Fertility and Sterility
August 2004
Differential sperm RNA profiles are associated with subsequent
blastocyst development
Janesch, Fertility and Sterility, September 2010

The sperm nucleus contains diverse populations of RNA that are potentially transmitted to the
oocyte at the time of fertilization. The functional role of these transcripts could include
contribution to embryogenesis and/or transcriptional gene silencing.

Infertile couples (n=16) undergoing IVF using donor oocytes (female factor standardized),
donated normozoospermic samples with consent. Cycles were divided into 2 groups relative to
blastocyst quality: Group A (Good) = ≥25% of D5 blastocysts ≥Grade 3BB, and Group B (Poor)
= <15% of D5 blastocysts ≥Grade 3BB. Total RNA was isolated from about 1 million sperm
(ICSI preparation, Group A=8 and Group B=8) and reverse transcribed for quantitative real-time
PCR.

Three genes, AKAP4, CLU and HSBP, exhibited significantly decreased expression in Group B
sperm samples compared with Group A (P<0.05). Both AKAP4 and CLU participate in biological
processes related to development. Following D5 blastocyst transfer, implantation rates
indicated a trend towards greater competence of Group A blastocysts (A=66.7% v. B=43.8%,
ns).

CONCLUSION: Differential sperm RNA profiles from donor oocyte IVF cycles reflected
subsequent D5 blastocyst quality. In particular, genes related to development showed a
decrease in expression in association with poor blastocyst development and competence.
Further studies are required to determine if these sperm transcripts indeed play a functional role
during embryogenesis.
ET Technique
 ET technique is critical to a successful pregnancy
outcome. The avoidance of blood, mucus, bacterial
contamination, trauma to the endometrium, touching
the fundus, and excessive uterine contractions are all
associated with better PRs and implantation rates.
 Utilization of a trial transfer, full bladder,
ultrasonographic guidance, and use of soft catheters,
all appear to facilitate a successful ET
New Methods of Embryo
Assessment
 time-lapse observations using an incubator with an
integrated optical microscope may minimize the changes in
the culturing environment by integrating the culture,
observation, and time-lapse recording of cells into one
system.
 Metabolomic analysis of follicular fluid (FF) can provide
valuable information about individual oocyte maturation and
developmental potential.
 Measurement of oxygen, pyruvate, and glucose
consumption by the embryo in the culture medium has been
correlated with viability. Amino acid turnover, which appears
to be correlated to blastocyst development.
Management options
 Lifestyle modification: BMI, smoking, alchohol
 Review stimulation:
 Dose of gonadotrophin may be increased or decreased. There is no firm evidence
that antagonist protocol is better than agonist protocol or vice versa.
 For poor responders to FSH stimulation in down-regulated cycles may benefit
from the addition of LH (Surrey and Schoolcraft, 2000). Evidence also points to a
possible benefit from the addition of LH to the cycles of women older than
35years of age (Balasch et al., 2001, Marrs et al., 2004, Phelps et al., 1999).
 In women with endometriosis and adenomyosis, the use of GnRH
agonists for a few months prior to IVF or ICSI may increase the
pregnancy rate (Sallam, Surrey)
Management options

Sperm DNA fragmentation



Medical treatment- oral antioxidant treatment has been shown to reduce the incidence of
sperm DNA fragmentation (Greco et al., 2005b).
Select spermatozoa with low levels of DNA damage (Sakkas and Alvarez, 2010).

use of annexin-V columns which has been shown to significantly reduce the percentage of
spermatozoa with DNA fragmentation as measured by the TUNEL test


sperm selection with hyaluronic acid binding (Jakab et al., 2005, Said et al.).
Intracytoplasmic morphologically selected sperm injection (IMSI) utilizes spermatozoa
selected under high-power magnification with a defined set of morphological criteria. A recent
meta-analysis comparing ICSI and IMSI outcome demonstrated a statistically significant
improvement in implantation and pregnancy rates and a significant decrease in miscarriage
rates with use of IMSI (Souza Setti et al., 2010)
It has been suggested that men with high levels of DNA damage in ejaculated spermatozoa have
spermatozoa removed surgically from the testis for ICSI (Greco et al., 2005a). The use of
testicular spermatozoa in couples with repeated implantation failure associated with high sperm
DNA fragmentation in semen has been reported to result in a significant increase in pregnancy
rate (Weissman et al., 2008) and reduction of miscarriage rate (Borini et al., 2006)
Management options
 Optimal culture media-Blastocyst transfer
 Zona hardening-Assisted hatching
 Screen for Chromosomal abnormalities: CCS
 Assessment of embryo quality and viability-Time-lapse imaging,
Metabolomics,Proteomics
 Improving ET technique
Fertility and Sterility
Volume 97, Issue 5 , Pages 1021-1027, May 2012
Co-culture
 The suggested beneficial effects of the co-culture
include the secretion of embryotrophic factors such as
nutrients, growth factors and cytokines and detoxifying
of free radicals and potentially harmful substances
(Simon et al., 1999).
 The most promising co-culture method seems to be
homologous endometrial cells (Jayot et al., 1995).
Using this method, Spandorfer et al. (2004) reported
49% PR in 1030 patients with RIF.
Blastocyst transfer
 Transfer of embryos at the blastocyst stage is a more
physiological approach because the human embryos enter
the endometrial cavity only 5 days after fertilization, at the
morula-blastocyst stage. Culturing the embryos to the
blastocyst stage evaluates embryos post embryonic genome
activation.
 Two large RCTs have shown that blastocyst transfer after
RIF following day 2–3 transfer carried significantly higher
implantation and live birth rates (Guerif et al., 2004; Levitas
et al., 2004). Improved embryo selection and uterine
receptivity may explain the benefit of embryo transfer at the
blastocyst stage for couples with RIF.
Prospective Randomized Trial of 1 vs 2 Blastocyst Transfer
90
80
70
(%)
60
1 Bc, n=23
50
2 Bc, n=25
40
Gardner et al. (2004)
Fertil Steril 81:551-5.
30
20
10
0
Implantation
OPR
Twins
Gardner, F&S, 2004
Single Cleavage Stage vs Single Blastocyst Transfer
Papanikolaou et al. (2006) N Engl J Med, 354: 1139-46
50
40
*
*
**
Day 3
30
Day 5
20
2 monozygotic twins
on day 3,
10
0
No monozygotics
were seen following
day 5 transfer
Implantation
Pregnant
Delivery
women were <36 years olds
Clinical pregnancy rate per randomized couple.
Papanikolaou E G et al. Hum. Reprod. 2008;23:91-99
© The Author 2007. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
CCRM:Vitrification versus Slow
Freeze
Vitrification, BC FET
D5, Slow Freeze, FET
# Cycles
n=441
n=272
% Blastocysts Survival
98.3%
83%
(P<0.05)
# Blastocysts Transferred
1.9
2.2
Clinical Pregnancy (fht)
71.9%
57%
(P<0.05)
Implantation Rate (fht)
54.6%
35%
(P<0.05)
Fresh vs Frozen SET
Shapiro, Fertility & Sterility, February 2013;99,2;
389-392,
Matched-cohort comparison of single-embryo transfers in fresh
and frozen-thawed embryo transfer cycles
Shapiro, Fertility and Sterility 2013; 99:389-392
FET Results in Better Outcomes and
Healthier Babies
•
Roque et al, 2012
Meta-analysis revealed significantly higher clinical
pregnancy rates following FET versus fresh transfer
• Pinborg et al, 2010
Singletons from FETs have significantly better neonatal
outcome than offspring from fresh transfers
• Henningsen et al, 2011
Birth weight was significantly higher in siblings born
after FETs compared with fresh embryos
CCS
Unexplained RIF Group
(n=130)
≥3 consecutive IVF failures
Unexplained Repeated Miscarriage
(RM) (n=77)
≥3 consecutive pregnancy losses
All embryos are grown to the
blastocyst stage for
trophectoderm biopsy
CCS using qPCR (RMA-NJ)
Frozen Embryo Transfer
Euploid embryos only
RIF and RM patients had no other infertility indications
Ovarian Reserve and Blastocyst Development
50
RIF Group (n=77)
45
40
37.3
RM Group (n=130)
36.3
35
30
25
20
16.6
17.5
15
10
5
7.9
2.4
7.4
5.4
5.6
2.2
0
Mean Maternal Age Mean AMH ng/ml
Mean D3 FSH
mIU/ml
No significant differences between the groups
Antral Follicle Count
# Blastocysts
Biopsied
Patients in the RM group are 1.35 times more
likely to have an aneuploid blastocyst
RIF Group
*
60
40
58.1%
*
43.6%
RM Group
56.4%
41.9%
20
0
Euploid
Aneuploid
*P<0.0001
4.5
***
4
3.5
3
***
***
2.5
2
*
*
1.5
1
0.5
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 X Y
More likely to be aneuploid in RM group;
* P < 0.05; *** P < 0.01
No significant difference in blastocyst
development, blastocyst quality or embryo
gender between the RIF and RM groups
IVF BC-CCS Cycle Outcome
*P<0.05; **P<0.001
90
84.5
RIF Group
80
76.4
RM Group
70
60
**
50
20
**
**
42.1
37.6
40
30
62.3
*
31.5
*
24.7
14.6
12.3
10
1.6
1.5
2.0
0
All Aneuploid Av # Transferred Implantation
Clinical
Cycle
(FHT)
Pregnancy (FHT)
MAB
Live Birth
(Retrieval)
Conclusion:
•
•
Overall, RIF patients did experience some benefit from the
transfer of a euploid blastocyst but not as significant as was
observed for RM patients of equivalent maternal age.
Even though embryo euploidy is essential for healthy fetal
development, other factors including flaws in endometrial
receptivity, embryonic function, and embryo-endometrium
dialogue should be further investigated in unexplained RIF.
CCRM
RCT of CCS vs Blastocyst
transfer in women >35
Infertile patients of maternal age >35 years were
computer randomized at oocyte retrieval into either:
Test Group
Control Group
All embryos are
grown to the
blastocyst stage
Day 5 Fresh Transfer
Embryo selection based on
morphology
Surplus blastocysts biopsied
for CCS prior to vitrification
Blastocyst biopsy for CCS on
either D5 or D6 (mean = 5.2)
CCS using SNP microarray technology
Frozen Embryo Transfer
Euploid embryos only
100% Survival from
Vitrification (n=74)
Post Warming
Prior to Transfer
IVF Cycle and Transfer Outcome
%
*
*
80
Control Group (n=41)
70
74.5
69.9
Test CCS Group (n=47)
60
53.7
50
40
39.8
40.5
39.5
30
18.5
20
10
4.7
6.0
*
2.2
2.8
1.6
0
Mean Maternal % No Transfer
Age (Years)
Mean #
Blastocysts
Transferred
Fishers Exact Test; *Significance = P<0.05
Implantation
Rate (FHT)
MAB Rate
Live Birth Rate
(Transfer)
Lipocalin-1: a potential marker for noninvasive aneuploidy screening
Source: Fertility and Sterility 2011; 95:2631-2633 (DOI:10.1016/j.fertnstert.2011.01.141 )
Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions
Forest plot of studies of clinical touch embyro transfer (CTET)
versus ultrasound-guided embryo transfer (UGET) for
outcome of clinical pregnancy rate.
Fertility and Sterility 2012; 97:1033-1038
Improving endometrial
receptivity
 Hysteroscopic correction of cavity pathology(Demirol and Gurgan,
2004)
 Patients with RIF who had a normal hysterosalpingogram were prospectively
randomized into office hysteroscopic evaluation (n = 210) or nothing (n = 211).
Patients who had abnormal hysteroscopic findings (n = 56) were operated on during
the procedure. Clinical PR was significantly higher in the treatment group (30.4%
following normal hysteroscopy and 32.5% following hysteroscopic operation)
compared to that in the controls (21.6%). Hence, treatment of intrauterine pathologies
found by hysteroscopic evaluation improved the pregnancy outcome.
 Myomectomy
 The favourable PRs obtained after myomectomy lead many clinicians to believe that
removal of myomas increases pregnancy and live-birth rates (review Donnez and
Jadoul, 2002). However, no appropriate prospective studies have been performed.
 No information on the value of myomectomy in RIF is available, although most
clinicians recommend hysteroscopic removal of submucous fibroids distorting the
uterine cavity.
 Treatment of thin endometrium
 Low-dose aspirin (Weckstein et al., 1997) and vaginal sildenafil (Sher and Fisch,
2002) were suggested in cases of RIF with thin endometrium.
 High-dose estrogens. Vaginal administration of micronized estradiol to maximize
estrogenic effect (Tourgeman et al., 2001)
 Antifibrotic treatment with pentoxifylline and high-dose vitamin E (Ledee-Bataille
et al., 2002) has been shown to increase PR in cases with a thin endometrium.
 Endometrial stimulation
 Barash et al. (2003) performed repeated endometrial biopsies in 45 cases.
Pregnancy and live birth rates in the IVF cycle following the biopsy were
doubled. They concluded that local injury to the endometrium increased the
incidence of implantation. There is a need for a prospective controlled study to
prove the value of this procedure.
Local injury to the endometrium doubles the incidence of successful pregnancies
in patients undergoing in vitro fertilization
Barasch, Fertility and Sterility
(June 2003)
Copyright © 2003 American Society for Reproductive Medicine Terms and Conditions
Local endometrial injury and IVF outcome: a systematic review and metaanalysis
Tarek El-Toukhy, SeshKamal Sunkara and Yakoub Khalaf
Reproductive BioMedicine Online
(October 2012)
Copyright © 2012 Terms and Conditions
Local injury of the endometrium induces an inflammatory response
that promotes successful implantation
Gnainsky, Fertility and Sterility
Volume 94, Issue 6 , Pages 2030-2036, November 2010
 Local injury by endometrial biopsy promotes an
inflammatory response.
 Proinflammatory cytokines such as TNF-α, produced by the
wounded endometrium, stimulate the secretion of other
chemokines/cytokines which, in turn, recruit
macrophages/DCs to the site of implantation.
 These immune cells enhance the inflammatory reaction and
may trigger the uterine epithelium to produce molecules that
interact with the blastocyst, facilitating its apposition and
attachment to the uterine wall.
Endometrial secretion analysis identifies a cytokine profile predictive of pregnancy in IVF
Flow-chart outlining the Endometrial secretion analysis identifies a cytokine profile predictive of
pregnancy in IVF
reasons for exclusion of women from analysis.
Boomsma C et al. Hum. Reprod. 2009;24:1427-1435
© The Author 2009. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
Receiver operating characteristic curve showing the area under the curves (AUC) to predict
pregnancy by the concentration of interleukin (IL)-1β, tumor necrosis factor (TNF)-α and
embryo quality (top quality embryo vs. suboptimal quality embryo).
Boomsma C et al. Hum. Reprod. 2009;24:1427-1435
© The Author 2009. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
Immunotherapy
 IVIF
 Stephenson and Fluker (2000) in a double-blind, placebo-RCT
including 51 couples with RIF found that IVIG did not improve
the live birth rate. Thus, the effectiveness of IVIG treatment in
RIF is still unresolved.
 Heparin and aspirin
 Two large RCTs indicated that heparin and aspirin did not
improve pregnancy or implantation rates in RIF (Urman et al.,
2000), even for autoantibody-positive patients (Stern et al.,
2003).
 Similarly, immunotherapy using partner’s leukocytes was not
shown to affect RIF (Carp et al., 1994).
Effect of heparin on the outcome of IVF treatment: a systematic review and
meta-analysis
Seshadri, Reproductive BioMedicine Online(December 2012)
Copyright © 2012 Reproductive Healthcare Ltd. Terms and Conditions
Treating endometriosis
 The administration of GnRH agonists for 3–6 months before
ART in women with endometriosis significantly increases the
ongoing PR (Surrey et al., 2002).
 No deleterious effect on ovarian response was observed. A
recent meta-analysis of three RCTs indicated that this
treatment increased the odds of clinical pregnancy by
(Sallam et al., 2006).
 Most investigators agree that there is no benefit in the
removal of endometriomas before IVF (Garcia-Velasco et
al., 2004; Wong et al., 2004). Furthermore, surgery might be
deleterious for ovarian reserve.
Outcome of highly purified menotropin (HP-hMG) vs recombinant follicle-stimulating
hormone (rFSH) in high responders
Arce, Gynecol Endocrinol, Early Online: 1–7
2014
Recommendations:
 Review prior cycles
 Optimize stimulation
 Optimize embryology: Day 5, AHA, CCS, FET
 R/O hydrosalpinx, Uterine pathology, abnormal
karyotype, DNA fragmentation
 If endometriosis or adenomyosis-Lupron or Letrozole
 If history of difficult transfer-laminaria
Recommendations:
 If high rate of CCS normals, consider GC
 If all abnormal on CCS, egg donation
 If male factor severe: age>60, high DNA fragmentation,
NOA, with good day 3 embryos but poor blastocyst
development, consider Sperm donation
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