Can
Endometrial Sractch/Injury
Improve Implantation ?
Prof.Timur Gürgan MD Gürgan Women’s Health,Infertility anf IVF Center
Ankara,Turkey
§ a recep've endometrium
§ a normal and func'onal embryo at the blastocyst developmental stage
§ a synchronized dialogue between maternal and embryonic 'ssues
Simon et al 2000
Successful implanta8on requires:
E8ology of Implanta8on Failure
§ Embryo Chromosomal abnormality
Low quality
§ Endometrial recep'vity Immune Factors
Endometriosis
Hydrosalpinx
Leiomyomas, Adenomyosis, PCOS,
Polyps, endometri's ..
Inflamation and Pregnancy
• During normal pregnancy ,the human decidua contains high number
of immune cels such as macrophages,natural killer (NK)
cells,regulatory T cells. And dentritic cells which infiltrate the
decidua and accumulated around the inviding trophoblasts cells
• The presence of immune cells at the implantation site is not associated with response to the foreign fetus but is attracted to
faciliated and protect the pregnancy
• Implantation,placentation and first and early trimester of pregnancy
resemble ’an open wound ‘ that requires a strong inflamatory
response (apposition,attachement and invasion)
• Epithelial and stromal changes (decidualisation and pinopode
formation /window of implantation )
• Modulation of different gene expressions of different
cytokines,chemokines,growth factors and adhesion molecules
The role of immune system at the impaltation site
• High level of the proinflamatory T helper cells (Th-1) and cytokines
(IL-6,Il-8,TNF alpha charecterize) early implantation
• Cytokines secreted by the endometrial cells and by the cells of immune system that are recuited to the site of implantation
• NK cells : regulates trophoblast invasion, sectretes angiogenic
factors to induce vascular growth and decidualisation,
• Macrophages:
*Pivotal role on cytokine balancing at the maternal-fetal interface.
*Essential for successful decidualisation
*Plays central role in the process of tissue renewal and differentiation
• Dentritic cells : Initiate and coordinate the innate immune adaptive
immune response and also support the effect of macrophages
Possible regulatory mechanisms for embryo-maternal cross- talk by immune system and endocrine systems
• Periferally circulating immune cells act on the reproductive organs to
facilatate embryo implantation Fujiwara,2006
• Peripheral immune /peripheral blood mononuclear cells(PBMC) cells in early pregnancy situmulate the corpus luteum function
• PBMC transmit the information presence of an embryo to various organs
throughout the body including the uterus and maternal vessels in order to
prepare and maintain the implantation Hashi ,1998
• PBMC promote endometrial cell receptivity Hosaka 2003
• hCG alters PBMC function to facilitate embryo invasion Kosaka,2002
• İmmune cells can induce early endometrial differentiation required for
subsequent implantation
• Succesful allopregnancy is a Th2 phenomenon in local balance in between Th1 and Th2 environment Chaoulat,2002
• Regulatory T cells and NK cells play impotatnt role in immune tolarence
and placentation and angiogenesis Hanna,2006;Saito,2008
Successful Implanta8on & RIF
Embryological and Endometrial Factors for RIF Cytokines Associated with Reproduc8on
Koot et. al., 2012. Biochem. Biophys. A.
Makrigiannakis et. al., 2011. J. Reprod. Immun.
Impaired recep8vity and Implanta8onin women with
endometriosis,adeneomyosis and PCOS
• Abnormally expression of endometrial receptivity biomarkers
PCOS Endometriosis ,Adenomyosis
• Integrins (αVβ3 integrin)
• Selectin
• Cadherin
• Glycodelin
• Osteopontin
• MUC1
• HOXA-10
• IGFBP-1
• NK cell activity
• Appoptosis
Endometrial Stimuli & Implantation
• Endometrial receptivity or the ‘window of
implantation’ is dependent on certain stimuli
Mechanical stimuli may activate the implantation :
• Endometrial biopsy
• Endometrial sctrach
• Endometrial injury
• Hysteroscopic approach
CONFUSIONS
§ Type of injury (biopsi/injury)
§ Instrumenta8on( cureUe/ pipelle/hysteroscopy)
§ Degree of injury (endometrium/myometrium)
§ Number of injury
§ Localiza8on of injury
§ Day /phase of menstruel cycle
§ Time between endometrial injury and embryo transfer cycle
§ Unselected popula8on or previous failures
Early prolifera8ve phase
Demirol and Gurgan 2004
Magrakis et al 2009
Rama Raju et al 2006
Early prolifera8ve and luteal phases
Barash et al 2003
Narvekar et al 2010
Luteal phase
Karimzadeh et al 2009
Raziel et al 2007
Once
Zhou et al, 2008
Shohayep & El-‐Khayat 2012
Coughlan et al, 2013
Twice
Raziel et.al, 2007(days 21,26)
Four 8mes
Barash et al,2003
(days 8,12,21,26)
Endometrial Injury
• Cycle preceeding IVF treatment
• During the treatment cycle
• Follicular phase or luteal phase
• Women with RIF and/or RPL
• Women undergoing IVF treatment
• More indica'on(s)……?
Barash et al., 2003; Raziel et al.,2007; Zhou et al.,2006 Coughlan et al.,2013
Endometrial Injury
• Endometrial injury on OPU day is
detrimental to IVF success rate Karimzade et al.,
2010
• Endometrium requires at least 2 weeks to
achieve complete repair after mechanical
injury Li et al.,2011
• Endometrial changes following injury are
sustained,and even increased in the
following cycle Kalma et al.,2009;Gnainsky et al.,2010
Endometrial Injury associated with :
• Local inflammatory response,cascading a release of pro-‐inflammatory cytokines ang growth factors like IL-‐ 6,IL-‐15,MIP-‐1B,LIF,osteopon'n and TNF alpha which induce decidualisa'on and development of endometrium favourable to implanta'on
• Gene expression in the endometrium,with up regula'on of pro-‐implanta'on proteins such as mucin 1 transmembrane (MUC1),cristallin alpha B,apolipoprotein D (APPOD),phospholipase A2 (PLA2) and uroplakin Ib (UPIb)
• Increase macrophages and dentri'c cells which play important role in decidualisa'on and implanta'on Kalma et al.,2009 ; Gnainsky et al.,2010
Overall,with local injury there are changes ini'ated within the endometrium the immune system and gene expression,all leading to improve recep'vity and favourable milieu for implanta'on. It could be that injury in the preceeding cycle is more effec've as all these events require 'me and are governed by the hormones.Interven'on closely to the embryo transfer can poten'ally disturb the endometrium and may have nega've effect
Endometrial biopsy Endometrial Injury
macrophages/dendritic cells
• tumor necrosis factor-a (TNF-a),
• growth-regulated oncogene-a (GROa), • interleukin-15 (IL-15),
• macrophage inflammatory protein 1B (MIP-1B),
• Osteopontin
A positive correlation was found between the levels of macrophages/dendritic cells, MIP-1B expression, and TNF-a expression & the pregnancy
outcome.
Gnainsky et al. Fertil & Steril 2010;94:2030
BACKWARD DEVELOPMENT HYPOTHESIS
Endometrial matura8on is abnormally advanced when controlled ovarian s8mula8on is performed during ART Lass et al.,1998; Ubaldi et al.,1997
COH cycles depicted structural and func8onal changes when compared with natural cycles, including histological advancement, pinopodes matura8on advancement and steroid receptor downregula8on Sebas8an et al., 2004
Endometrial injury performed in the previous cycle might retard endometrial matura8on leading to beUer synchronicity between the
endometrium and the transferred embryo Li et al., 2009
Results: Endometrial sampling of IVF patients using a biopsy catheter substantially increases their chances to conceive at the following IVF-embryo transfer cycle. By
transferring a similar number of embryos in the study and control groups, the authors achieved an implantation rate of 28 versus 14%, a clinical pregnancy rate of 67
versus 30% and a live birth rate per embryo transfer of 49 versus 23%.
Conclusion: These results suggest that IVF treatment that is preceded by
endometrial biopsy doubles the chance for a take-home baby.
Clinical pregnancy rate in the endometrial injury (hysteroscopy and
endometrial biopsy) and control groups.
Potdar,2012
Live birth rate in the endometrial injury (hysteroscopy and endometrial
biopsy) and control groups
Potdar,2012
Live birth rate in the randomized and non-randomized studies for
endometrial injury and control groups.
Potdar,2012
Peer review is the basis for the crea'on of solid and trustable knowledge that we can implement in the treatment of our pa'ents. Now, this concept is being tainted and diluted by a
vicious circle created by the use of inadequate or insufficient data to compute incorrect or incomplete conclusions that are touted as evidence-‐based medicine, crea'ng confusion
instead of clarifica'on.
Endometrial straching prior star8ng ART treatment
may improve the chance of implanta8on ?
• First publica'on made by Barash et al., in 2003 decade later this interven'on being used widely by some colleaques widely advier'sed on their the web sites and pa'ents are paying to undergo ‘straching cycle ‘ before their ART treatment cycle !
• Following a ‘trustworthy’ evidence-‐based medical approach,these colleaques believe that there giving the pa'ents the best treatment possible because new treatment op'on based on more thn 300 referances (case series,case reports,case controlled studies,expert opinions etc. ), 4 randomised RCT and 3 meta –analyses
• RCT published in journals very low impact factors • Meta-‐analyses some very important methodological problems( different
pa'ent groups,different defini'on of RIF, some pa'ents have no implanta'on failure,different interven'on procedures and techniques etc. )
• There is no enough data and it is not sufficiently conclusive to merrit such confidance in this interven'on !
Endometrial straching prior starting ART treatment may improve the chance of implantation ?
• In the second systamatic review Potdar (2012),include the which have been already analysed,and hysteroscopy was included as another way of injuring endometrium. It should be kept in mind that hysteroscopic intervention may give additional benefit to the effect of the endometrial stracthing alone !
• Combined effects of various procedures (using OC,GnRHa,GnRHant
• Incorrect choosing of the studies to be included
• If you put trush in, you get the trash out ????
Simon C and Bellver J, HR,2014
• Is there evidence to demonstrate that ‘straching ‘ in the previous cycle modulates molecular/cellular phenotype induced by COS ?
WHAT DO YOU THINK ?
Conclusion
There is an urgent need for large,mul8centre randomised studies inves8ga8ng local endometrial injury and pregnancy outcomes in the unexplained RIF,in pa8ents unexplained subfer8lity undergoing first IVF cycle and some pathologies with dimineshed endometrial recep8vity such as PCOS and endometriosis
The evidence must be strengthened by simultenous molecular and gene expression studies on endometrium
Un8l the results of such studies available,or an expert consor8um quideline proposed,it should be a blanket policy to induce local endometrial injury for women undergoing first cycle of IVF and perhaps there is a role for this in women with unexplained RIF
Systema8c and standardized hysteroscopic endometrial injury
for treatment of recurrent implanta8on failure (RIF):
Preliminary results of prospec8ve and randomized trial.
Timur Gürgan1, Ziya Kalem1, Işın Kocabaş1, Müberra Namlı Kalem2, Halil Ruso1, Antonis Makrigiannakis3
1: Gürgan Clinic Women’s Health and IVF Centre, Ankara, Turkey. 2:Turgut Özal University Hospital, Department Obstetrics and Gynecology, Ankara, Turkey.
3: University of Crete, Department of Obstetrics and Gynecology, Crete, Greece
Purpose: To inves'gate the effect of hysteroscopic symmetrical endometrial injury for RIF pa'ents.
Method: This is a prospec've and randomized controlled trial for RIF pa'ents inves'ga'ng the effect of systemic and symmetric endometrial injury using office
hysteroscopy. Endometrial injury was performed on the follicular phase of the
menstrual cycle under general anesthesia. The main variant analyzed was the clinical pregnancy rates. Sta's'cal calcula'ons were performed on GraphPad Prism version
6.0 and p<0.05 were considered sta's'cally significant. Findings: Following randomized controlled trial we propose that the systemic
endometrial injury model can be standardized to increase the odds of implanta'on in
RIF pa'ents to achieve clinical pregnancy.
Our Technique :
§ Symmetric,systema8c Injury on the fundus
a. One transverse incision
b. Symmetric ver8cal incisions (6-‐8) around line
§ Hysteroscopy
§ Follicular phase
§ Previous cycle before ET
§ RIF
RIF(Recurrent Implantation Failure):
Failure to achieve a clinical pregnancy aher 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 years.
Systema8c and standardized hysteroscopic endometrial injury
for treatment of recurrent implanta8on failure (RIF):
Preliminary results of prospec8ve and randomized trial.
Timur Gürgan1, Ziya Kalem1, Işın Kocabaş1, Müberra Namlı Kalem2, Halil Ruso1, Antonis Makrigiannakis3
1: Gürgan Clinic Women’s Health and IVF Centre, Ankara, Turkey. 2:Turgut Özal University Hospital, Department Obstetrics and Gynecology, Ankara, Turkey.
3: University of Crete, Department of Obstetrics and Gynecology, Crete, Greece
Purpose: To inves'gate the effect of hysteroscopic symmetrical endometrial injury for RIF pa'ents.
Method: This is a prospec've and randomized controlled trial for RIF pa'ents inves'ga'ng the effect of systemic and symmetric endometrial injury using office
hysteroscopy. Endometrial injury was performed on the follicular phase of the
menstrual cycle under general anesthesia. The main variant analyzed was the clinical pregnancy rates. Sta's'cal calcula'ons were performed on GraphPad Prism version
6.0 and p<0.05 were considered sta's'cally significant. Findings: Following randomized controlled trial we propose that the systemic
endometrial injury model can be standardized to increase the odds of implanta'on in
RIF pa'ents to achieve clinical pregnancy.
Systema8c and standardized hysteroscopic endometrial injury for
treatment of recurrent implanta8on failure (RIF): Preliminary results of
prospec8ve and randomized trial. Gurgan et al.
Control (n=40) Injury (n=44)
Average female age 30.76 33.48
Av. BMI 23.28 24.35 Av. No of previous cycles 3.57 3.57 Av. No of cumulative ET 6.29 6.26
Av. No of COCs 6.17 6.51
Av. No of MII eggs (%) 73.81 77.12
Av. Fertilisation rate (%) 96.53 89.24 Average ET day 3.14 3.09
Av. no of embryos transferred 1.9 2.02
Av. Endometrial thickness on
hCG day 10.33 9.46
Injury Performed NO YES
Av. cycle day of Injury - 10.86
Av. time from Injury to ET
(days) - 56.02
Clinical Pregnancy 17.50% 40.91% (p=0.02)
Implica8ons for Research
Is endometrial injury effective in other ART situations ?
• Cryopreserved embryos or gametes
• Embryo or gamete donation
• Uterine abnormalies
• Endometriosis /endometriomas
• Adenomyosis
• PCOS
• Any significant effect on
Miscarriage rate
Multiple pregnancy rate