repeated implantation failure
TRANSCRIPT
Wednesday May 3 2023
Why my IVF cycle failed
Ahmad Saber Soliman
A guide to learn from your failed IVF cycle
Wednesday May 3 2023
Objectives
bull Definition of repeated IVF failureHow many attempts How many embryos
bull Avoidable causes of IVF failureFailure in the presence of potential obstacles
Wednesday May 3 2023
Definition
Wednesday May 3 2023
Its definition is dynamic and depends on the population of patients studied as well as the type and quality of clinical practice Mitri et al 2016
no universally accepted definition for RIF despite many publications on this topic (Das and Holzer 2012 Laufer and Simon 2012 Penzias 2012 Simon and Laufer 2012ab Urman et al 2005)
Wednesday May 3 2023
Implantation failure after transfer of three high-quality embryo or with transfer of ge10 embryos in multiple transfers with exact numbers to be determined by each center
[Thornhill AR ESHRE PGD Consortium et al Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) Hum Reprod 200520(1)35ndash48]
Should be revised after the era of SETDET
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Objectives
bull Definition of repeated IVF failureHow many attempts How many embryos
bull Avoidable causes of IVF failureFailure in the presence of potential obstacles
Wednesday May 3 2023
Definition
Wednesday May 3 2023
Its definition is dynamic and depends on the population of patients studied as well as the type and quality of clinical practice Mitri et al 2016
no universally accepted definition for RIF despite many publications on this topic (Das and Holzer 2012 Laufer and Simon 2012 Penzias 2012 Simon and Laufer 2012ab Urman et al 2005)
Wednesday May 3 2023
Implantation failure after transfer of three high-quality embryo or with transfer of ge10 embryos in multiple transfers with exact numbers to be determined by each center
[Thornhill AR ESHRE PGD Consortium et al Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) Hum Reprod 200520(1)35ndash48]
Should be revised after the era of SETDET
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Definition
Wednesday May 3 2023
Its definition is dynamic and depends on the population of patients studied as well as the type and quality of clinical practice Mitri et al 2016
no universally accepted definition for RIF despite many publications on this topic (Das and Holzer 2012 Laufer and Simon 2012 Penzias 2012 Simon and Laufer 2012ab Urman et al 2005)
Wednesday May 3 2023
Implantation failure after transfer of three high-quality embryo or with transfer of ge10 embryos in multiple transfers with exact numbers to be determined by each center
[Thornhill AR ESHRE PGD Consortium et al Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) Hum Reprod 200520(1)35ndash48]
Should be revised after the era of SETDET
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Its definition is dynamic and depends on the population of patients studied as well as the type and quality of clinical practice Mitri et al 2016
no universally accepted definition for RIF despite many publications on this topic (Das and Holzer 2012 Laufer and Simon 2012 Penzias 2012 Simon and Laufer 2012ab Urman et al 2005)
Wednesday May 3 2023
Implantation failure after transfer of three high-quality embryo or with transfer of ge10 embryos in multiple transfers with exact numbers to be determined by each center
[Thornhill AR ESHRE PGD Consortium et al Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) Hum Reprod 200520(1)35ndash48]
Should be revised after the era of SETDET
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Implantation failure after transfer of three high-quality embryo or with transfer of ge10 embryos in multiple transfers with exact numbers to be determined by each center
[Thornhill AR ESHRE PGD Consortium et al Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) Hum Reprod 200520(1)35ndash48]
Should be revised after the era of SETDET
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Recurrent implantation failure vs
Recurrent IVF failureRIF is not the same as recurrent IVF
failure Recurrent IVF failure is the failure to achieve a pregnancy after several IVF attempts a common cause being poor response to ovarian stimulation (Ferraretti et al 2011)
The term lsquorecurrent implantation failurersquo is a subgroup of recurrent IVF failure and should not be used to replace it Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
What is implantation rate number of embryos which have produced US evidence of an intrauterine gestational sac per the total number of embryos transferred into the uterine cavity (Zegers-Hochschild et al 2009)
when day-2 or -3 embryos are transferred is about 25 But when day-5 or -6 embryos are transferred is usually higher about 40
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Is chemical pregnancy considered as implantation
failure
Clinically Implantation failure refers to the failure of the embryo to reach a stage when an IU gestational sac is recognized by ultrasonography
ie the only clinical evidence of implantation is appearance of IU gestational sac
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
The common defendants
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Embryo transfer
technique( Angelini et al 2006)
Uterine receptivity
(Modi et al 2012 Strowitzki et al 2006)
EggEmbryo quality
(Karlstrom et al 1997)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Age is the most important single variable affecting outcome in ART (Rosenwaks et al 1995)
Effect on oocyte quality and endometrial receptivity
Age
cause or prognosticator
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Pregnancy depends on implantation of a
developmentally competent embryo to dip in a receptive
endometrium
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Establishing the relationship between soilseed
Endometrium embryoSoilseed
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Maternal bullEndometrial Factors bullUterine Factors
bullObesity
bullThyroid
bullEndometriosis(13 of them has NK cell activation )
bullImmunological Factors (maternal tolerance to the baby )immunologic system plays a role in the process of implantation and in the subsequent maintenance of pregnancy Chaouat et al 2007Singh et al 2011
Embryo bull Gamete (Sperm DNA damage-Oocyte quality)
bull Zona Hardening
bull Inadequate culture
Doctor
Bad ET technique
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Management of RIF
Over thinking may create false problems
Try to find and evidence
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
previous IVF treatment cycles
Clinical drugs used during ovarian stimulation number of oocytes retrieved
Lab method used for fertilization fertilization rate embryo development
Clinical day and ease of embryo transfer procedure
Detailed history
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Counseling should precede the investigative process to
ensure patients understand the rationale potential benefit and cost implications of the proposed testsPreferablyinformation leaflets should augment the counseling process
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
High-resolution ultrasound scanning
Hysteroscopy
Screening for congenital and acquired thrombophilic conditions
Evidence-based investigations should include
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Other commonly performed investigations with weaker evidence base include
karyotype analysis for the couple laparoscopy for diagnosis and treatment of
endometriosis and endometrial biopsy Has it had a place in
modern practice
The role of immunologic testing for natural killer cell counts and cytotoxicity assay remains controversial
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Anatomical uterine factors
Salpigectomy
myomectomy
polypectomy
metroplasty
Adhesolysis
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
bull Polypsbull adhesions bull submucous fibroids (FIGO 0-2) bull endometritis
Rationale Searching for correctable pathology in up to 45 of patients with RIF
Even in the absence of identifiable pathology there is evidence that performing hysteroscopy could still improve the likelihood of pregnancy in the subsequent IVF cycle [El-Toukhy et al 2008 systematic review and metaanalysis ]
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Hysteroscopic resection of the septum improves the reproductive outcome of infertile women (Bakas et al 2012 Mollo et al 2009)
Uterine septum
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
bull After polypectomy
patients can undergo ovarian stimulation after their next menses after a polypectomy without affecting assisted reproductive treatment outcomes (Pereira et al 2016)
Postpone assisted reproductive treatment for 2 months after hysteroscopic septoplasty and for 3 months after myomectomy or adhesiolysis Yang et al (2013(
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Hydrosalpinx
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Does it affect IVF results
altered endometrial histology and a lack of expression of endometrial adhesion molecules )integrins( which may play important roles in the implantation process )Meyer et al 1997(
Reflux of hydrosalpinx results in mechanical factors diminishing embryonic endometrial apposition )Sharara 1999(
Hydrosalpinx fluid contains embryotoxic inflammatory compounds )Mukherjee et al 1996(
Two meta-analyses estimated that hydrosalpinges diminished implantation rates by 35ndash50 And also responsible for early pregnancy loss (Zeyneloglu et al 1998 Camus et al 1999)
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Laparoscopic salpingectomy or proximal tubal occlusion
Options for management
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Bilateral salpingectomy results in improved implantation as well as pregnancy rates compared with controls who harbor hydrosalpinges (Bredkjaer et al 1999) Dechaud et al 1998 Strandell et al 1999All studies were done on females aged lt39 years Improved pregnancy rates in patients who had hydrosalpinges and underwent laparoscopic salpingectomy after experiencing repeated implantation failure (Dechaud et al 2000)
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response Fan et al 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either interruption of tubal uterine patency or ultrasound-guided drainage of hydrosalpinges might also be considered
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Endometrial thickness
and receptivity
Asprin
G-CSF
Sildenafil
Endometrial scratching High dose estrogen
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Endometrial scratching before IVF
bull Mechanical manipulation was shown to be associated with decidual formation in guinea pigs
bull Endometrial scratching during the progestational phase of estrous cycles provoked a rapid growth of decidual cells
Loeb L Zentralblatt fur allgemeine Pathologie und pathologischeAnatomie 18 563ndash565 1907
The 1st evidence is reported at the
beginning of the 20th century
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
In women with RIF inducing local injury to the endometrium in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes However large studies are required before this can be adopted in routine clinical practice Potdar et al 2012 a systematic review and meta-analysis
Timing Endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer )ET( cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers
Not advised in day of oocyte retrieval as it was associated with a reduction of clinical and ongoing pregnancy rates
[Cochrane Database Syst Rev 2015]
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Poor Endometrium
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Inadequate endometri
umRefractory endometriumendometrial
thickness or pattern seem inadequate
where it seems difficult or impossible to make it grow
Wednesday May 3 2023
endometrial thickness under 7 mm would define a refractory endometrium with compromised success rates (Dix and Check 2010 Kasius et al 2014) Although prevalence is low )24 according to Kasius et al 2014( it still represents a challenge today
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Causes of refractory endometrium
Surgicaldilation and curettageD amp C a risk factor for adhesion formation )40 of cases o IUA) )Hooker et al 2014(
partial ablationmyomectomypost-Strassman
RadiotherapyInfections (endometritis)Congenital Muumlllerian anomaliesIdiopathic Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
US assessment of endometrial receptivity of clinical significance
bull Thicknessbull Echogenicitybull Doppler assessment of uterine and spiral artery flow
Wednesday May 3 2023
imaging technologies can provide information about endometrial receptivity up to a certain stage as pregnancies have been described even in thin endometria lt5 mm as well as in hyperechogenic endometria So molecular technologies will help us to further understand endometrial receptivity but still needs to be validated in a prospective trials (Cruz and Bellver 2014)
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
hypoechogenic endometrium was more receptive than the iso- or hyperechogenic endometrium before hCG triggering ie progesterone effect (Check et al 1993)
Echogenicity
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
no agreement has been reached on endometrial thickness Although most clinicians empirically prefer endometria gt7 mm available evidence does not support any specific thickness as pregnancies with similar success have been described from 5 mm to more than 15 mm )Cai et al 2011 Remohn et al 1997(
Endometrial thickness
Is their is minimal endometrial thickness required to establish a clinical pregnancy after
ART
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Endometrial pattern
Wednesday May 3 2023
A triple line multilayered pattern seems to be associated with conception cycles in IVF
Dickey et al Hum Reprod 1992 Serafini et al Ferti Steri 1998
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Chronic endometritis
women with CE show altered uterine contractility may explain the symptoms related to CE and infertility (Pinto et al 2015)
Wednesday May 3 2023
Kasius et al 2011 reported a 28 prevelance of chronic endometritis among
infertile women
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Clinical relation between RIF and CE
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Diagnosing CE
Hysteroscopy is reliable in diagnosing Chronic endometritis and it can assess clinical effectiveness of antibiotic therapy )Among 211 patients with CE diagnosed by hysteroscopy 200 cases were confirmed histologically( (Guo et al 2013)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
(B) At histologystroma of micropolyps is characterized by an accumulation of inflammatory cells )lymphocytes plasma cells or eosinophilic granulocytes( intermingled with normal stromal cells around small vessels and glandular structures
)A(Endometrial micropolyps
Micropolps is considered a reliable diagnostic sign for CE )Ettore et al 2005(
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Criteria proposed by Cicinilli et al 2005 to establish the diagnosis of chronic
endometritisbull Hyperemia the vascular pattern seen accentuated
at the periglandular area
bull Stromal edema if the endometrium examined during proliferative phase it was seen thickened and pale
bull Micropolyps small vasecularized pedunculated protrusions of the uterine mucosa lt1mm )PPV 984)
And they concluded that absence of stromal edema and hyperemia has a )NPV 988)NB presence of itrauterine synechia is a severe form on long term sequalea of chronic endometritis
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Prehysteroscopic diagnosis No pathognomonic features While may be suspected by indirect features bull Tender probing bull women with CE show altered endometrial patterns in both
the periovulatory and midluteal phases (Pinto et al 2015)
bull ECF
bull Folliculo-endometrial asynchorony )increased endometrial thickness asynchronous with follicular growth(
bull Intracavitary synechiae ) 3D SIS (Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Management of refractory endometrium
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Medical therapeutic strategies
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023beneficial
Evidenve with is lacking Not of benefit
Hormonal strategies
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Route OralType in Market oestradiol valerate (Lignieres et al 1986)
Duration for up to 9 weeks with no adverse effects such as endometrial hyperplasia or bleeding (Chen et al 2006 Remohiacute et al 1995)
Dose )6 minus 8 mg or up to 16 mg( continuously from cycle day 1 unless tolerance is poor In general 2 mg suffice to block HPO axis
Wednesday May 3 2023
No value of progressive step-up increase in the dose that simulates a natural cycle (Coughlan et al 2014 Shen et al 2013)
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Q does estrogen addition as an adjuvant to progesterone in the luteal support of value
or not
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Estrogen increase clinical pregnancy rate
but its role in management of refractory endometrium is still
lacking an evidence
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
HCG injection in the proliferative phase
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Where receptors of hCG present
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Granulocyte-colony stimulating factor (G-CSF)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
G-CSF supplementation modulated expression of genes that play a role in endometrial vascular remodelling local immune regulation and cell adhesion )Rahmati et al 2014)Limited experience in women with recurrent miscarriage )Santjohanser et al 2013( and repeated implantation failure )Wurfel et al 2010( after undergoing IVF with G-CSF supplementation is available
Wednesday May 3 2023
when a well-designed adequately powered proper RCT was done by the pioneers of this concept they were unable to demonstrate any effect of G-CSF on either endometrial growth or pregnancy rates in women undergoing IVF )Baradet al 2014)
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Low-dose aspirin
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
After wide application of doppler US and assessment of subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate )184 versus 9( as well as an improved endometrial pattern although the endometrial thickness and uterine vascular flow parameters remained unchanged )Hsieh et al 2000)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Use of LDA to improve pregnancy rate in patients undergoing IVF treatment if not supported Dentali et al 2012 Meta analysis ndash systematic review
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Pentoxifylline
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
synthetic derivate of methylated xanthine
Mechanism of action intracellular cAMPVD-increased RBCs deformability
Dose 800 mg pentoxifyllin plus 1000 IU vitamin E for 6 minus 8
months
Its administration is associated with increased ET (Letur-Konirsch and Delanian 2003) Acharya et al (2009)
Effect is enhanced when co-administered with vitamin E )Chiao and Lee 2005(
Administration should be suspended before ET
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Nitroglycerin
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
There is no current evidence to support the use of nitroglycerin patches in women with a thin endometrium
Nitric oxide )NO( is involved in endometrial cycle control and uterine preparation for pregnancy
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Sildenafil
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase the enzyme that hydrolyses cGMPMode of action bull enhances the vasodilator effect of nitric oxide by
reducing cGMP degradationbull endometrial growth facilitating effectbull reduce natural killer cell activity which may be of
interest for women with recurrent miscarriages (Jerzak et al 2008)
Dose 25 mg6 h in vaginal suppositories in the proliferative phase and administration was stopped prior to HCG administration or embryo transfer Sher and Fisch (2000)Zinger et al (2006) described two successful cases in women with Asherman syndrome
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
endometrial epithelial cell culture has been reported to have a very moderate effect on cell proliferation but no significant changes were found in nitric oxide concentrations (Khazaei et al 2011)
So although biological conflict with the clinical evidence exists any evidence for the clinical benefit of sildenafil in women with a recurrent thin endometrium is weak and very few publications on non-randomized studies have been found with very few patients included
No benefit of sildenafil on endometrial growth in a prospective randomized study Check et al (2004)
Conversely
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
GnRH analogues
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
According to Qublan et al (2008) the administration of GnRH )triptorelin 01 mg on the day of oocyte retrieval day of embryo transfer and 3 days later( plus conventional luteal phase support significantly improved implantation and pregnancy rates However no other study has validated these findings
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Luteal phase GnRH agonists in cases of RIF
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
A RCT done by Simin et al 2015 concluded that in addition to routine luteal phase support using progesterone administration of 01 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVFICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol
In a meta-analysis evaluating Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles (Oliveira et al 2010) they conclude that luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Thrombophilia LMWHAspirin
Immunological factors
Intralipid IVIG
Steroids
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Uterine receptivity
Endometrial thickness
Uterine lesions
Immunological
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Immunological implantation dysfunction
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
bull Autoimmunity Misdirected immune response when an immune system attacks its own tissues
bull Alloimmunity The immune system attacks foreigen tissues from the same species eg graft rejection
More than 85 of immunological causes of RIF is autoimmune in
origin
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Autoimmune implantation dysfunction
Primary bull SLEbull Rhumatoid arthritis bull Hashimoto thyroidiits bull OthersSecondary ( Reactionary )bull EndometriosisIdiopathic
All are associated with increased levels of ANA ( relation to RIF or RPL)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
bull Hepriniods Enhance phspholipid production by
trophoblast Repel APA production from trophoblast Anti- ThromboplastinDecrease platelet adhesiveness
bull Intralipids gtgtgtgtgtgtgtgt aNK suppressors
bull Immunoglobulins )IVIG( very expensive many risks
bull DexamethazonePrednisone gtgtgtgtgtgtgtgtgtgt CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
bull Others ) LITHumeraAspirins(
Implantation immunotherapy
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Intralipid 20
Routinely used for parenteral nutrition intralipid is a fat emulsion that was reported to suppress abnormal NK cytotoxic activity in peripheral NK cells from women with recurrent reproductive failure both in vitro and in vivo Roussev et al 2008
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Content Intralipid 10 1000ml contain )purified soybean oil 100g purified egg phospholipids 12g glycerol anhydrous 22g water for injection It is composed of 10 soybean oil 12 egg yolk phospholipids 225 gylcerine and water
Dosage 2g of fatkg body weightday )20ml 10ml and 67mlkg of intralipid 10 20 and 30 respectively(
Infusion rate The drip rate is about 2 to 3 mlmin for intralipid 10 It should be started at half the infusion rate during the first 30mins under supervision
IVF protocol bull 7-14 days prior to ET bull Repeated on the day of ET bull Repeated again with a positive pregnancy test and
administer every month until the 20th week Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
propofol is widely used and in volume doses that are higher than those suggested for the treatment of RIF
many IVF programs perform egg retrieval by general anaesthesia applying propofol as a short acting hypnotic agent Propofol solution contains the same components of intralipid emulsion )10 soybean oil and 12 purified egg phospholipid with 225 glycerol( supplemented with 1 propofol
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Role of IVIG
The only properly conducted prospective RCT by stephenson amp Flucker (2000) involving 51 women with 2 or more IVF failure showed IVIG of no benefit
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane data base 2007 ( showed no evidencing benefit routine use of steroids in women undergoing IVF
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Empiric use of Aspirin
bull No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Anticardiolipin antibodies
bull Two studies showed higher prevalence of ACA in women with RIF ( Kaider et al 1996 amp Qublan et al 2006 )
bull However the only RCT in the use of LDA or Heparin in cases of high levels of ACA shows no benefit in cases of RIF (stern et al 2003 )
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead to NK cells activation that become permanent
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Screening for Inherited and acquired thrombophilic conditions
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
when summarizing all studies focusing on gene polymorphisms and the thrombophilia trait it seems that prothrombotic disorders are more prevalent in RIF patients than in controls [Toth et al 2011]
Wednesday May 3 2023
Relation between thrombophilia and RIF
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
While empiric treatment with heparin is not justifiable Altogether it is recommended that patients diagnosed with RIF be investigated for acquired as well as hereditary thrombophilia disorders and be treated accordingly Berker et al 2011Seshadri et al 2011Urman et al 2009
serum testing for congenital and acquired thrombophilia could be useful in identifying patients who could benefit from adjuvant LMWH and low dose aspirin [Qublan et al 2008]
What about empiric use of LMWH in ART patients
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic factors
Blastocyst transferAssisted hatching
Sequential transfer
ZIFT
Co-culture system
EmbryoGlue
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Male factor contribution IMSI
Genetic factors PGD
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
The embryo
bull Qualitybull Number transferredbull Stage of developmentbull Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure
Rate limiting step in human reproduction
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Is morphological grading is sufficient
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Embryonic interventions that may improve IVF success
Pre implantation genetic diagnosis and other methods for embryo selection
preimplantation genetic screening (PGS) hellip Time lapse imaging
Blastocyst transfer
Assisted hatching
Sequential ET
IMSI
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Not suitable for all patients bull to patients who are younger in age and
produce over six oocytes[Levitas et al 2004]
Blastocyst transfer
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
activation of the embryonic genome occurs at the eight- to 10-cell stage )day 3 of culture(
Embryos that cleave after day 3 in culture therefore are no longer dependent on maternal RNA transcripts and have made the successful transition from maternal to embryonic genomic control
Why blastocyst is more competent
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Q Is blastocyst transfer is a successful treatment in cases of RIF
live birth after fresh IVF is significantly higher after blastocyst-stage embryo transfer as compared to cleavage-stage embryo transfer when equal number of embryos are transferred in the two groups compared Papanikolaou et al 2008 systematic review and meta-analysis
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona thickness seemed to have a good prognosis for implantation (Cohen et al 1989)
Methods Mechanical or with a piezo-micromanipulator )Nakayama et al1998( or by laser )Hsieh et al 2002(Hazardsbull Direct damage to blastomeres-Incomplete hatching-
Premature hatching
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
AH was related to increased clinical pregnancy and multiple pregnancy rates in women with RIF Das et al 2009 Cochrane review Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates particularly in poor prognosis patients including those with RIF Poor quality embryo and Older women )38 or more( while routine practice is not supported ASRM 2007 committee opinion
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Preimplantation Genetic Diagnosis (Aneuploidy Screening)
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Extraordinary genetic diversity of the human embryos at implantation
That put another question about the value of PGS before embryo transfer
Is it a help or a hype
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Guideline
Available evince of does not support the use of PGS for patients with RIF ASRM committee opinion 2007
What about 2nd generation PGS
Whole genome amplification (WGA)
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Hyaluron enriched embryo transfer medium (EmbryoGlue)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
In 42 women undergoing IVF embryos were transferred into 50 μL of EmbryoGlue for 10 min prior to transfer inside uterine cavity In the control group )n = 42( embryos were transferred to conventional blastocyst culture medium in patients with recurrent implantation failure it may be considered as a useful transfer medium Neeta et al 2015
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Evidence suggests improved clinical pregnancy and live birth rates with the use of functional concentrations of EmbryoGlue as an adherence compound in ART cycles However the evidence obtained is of moderate quality The increase in multiple pregnancy rate may be the result of use of a combination of an adherence compound and a policy of transferring more than one embryo Further studies of adherence compounds with single embryo transfer need to be undertaken Cochrane review 2015
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Two tests encountered with cases of RIF
Sperm Chromatin Structure Assay )SCSA( Sperm chromatin dispersion test )SCD(
DNA fragmentation index gt27 RIF )Larson et al2000 Larson-Cook et al 2003)
Sperm as a cause of RIF DNA fragmentation
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
sperm DNA fragmentation is not an important cause of RIF and there is a significant differences between test methodologies in interpreting the data Carol et al 2015
SDF is not related to chromosomal anomalies in embryos from patients with implantation failure Furthermore the different methods used to evaluate DNA fragmentation may produce different results F Bronet human reprod 2012
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
The results of DNA testing alone can not predict reproductive outcome in patients of ART
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
IMSI
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
IMSI is a real-time method where sperm is selected before the microinjection takes place to identify spermatozoa devoid of surface vacuoles
By using an inverted microscope that is able to provide much greater magnifying power )around 6000 times( than that normally used in reproductive laboratories )400 times( to carry out ICSI (Bartoov et al 2003)
The only confirmed indication for IMSI is RIF while routine use in IVF practice still not recommended (Boitrelle et al 2014)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
ET Technique as a cause of IVF failure
bull Mock transfer in prior cycles Introducing infection Better to map your transfer technique before
bull Full Bladder
bull US guidance Their in no excuse for non US guided ET
bull Sequential embryo transfer bull Interval double ET )on days 2 and 4 or 5(
improves CPR in RIF (Loutradis et al 2004 Almog et al 2008)
Wednesday May 3 2023
Is FET cycles is an easy and good alternative
Wednesday May 3 2023
Vitrification is Ultra-Rapid freezing method the keep the biological and chromosomal
integrity of the embryo
Frozen Embryo Transfer Baby born January 1991 now age 21 Michael with his mum Karen Robinson
Wednesday May 3 2023
One in 4 females has displaced window of implantation so need PET and ERA
test
Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive or not
pET performed on the day designated by the ERA 500 PR and 385 IR (Ruiz-Alonso et al 2013)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
Is FET cycles is an easy and good alternative
Wednesday May 3 2023
Vitrification is Ultra-Rapid freezing method the keep the biological and chromosomal
integrity of the embryo
Frozen Embryo Transfer Baby born January 1991 now age 21 Michael with his mum Karen Robinson
Wednesday May 3 2023
One in 4 females has displaced window of implantation so need PET and ERA
test
Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive or not
pET performed on the day designated by the ERA 500 PR and 385 IR (Ruiz-Alonso et al 2013)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
Vitrification is Ultra-Rapid freezing method the keep the biological and chromosomal
integrity of the embryo
Frozen Embryo Transfer Baby born January 1991 now age 21 Michael with his mum Karen Robinson
Wednesday May 3 2023
One in 4 females has displaced window of implantation so need PET and ERA
test
Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive or not
pET performed on the day designated by the ERA 500 PR and 385 IR (Ruiz-Alonso et al 2013)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
One in 4 females has displaced window of implantation so need PET and ERA
test
Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive or not
pET performed on the day designated by the ERA 500 PR and 385 IR (Ruiz-Alonso et al 2013)
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
bull Many known and unknown reasons for RIF and we do not have the tools to diagnose in each case the exact cause
bull The management of RIF should be individualized multidisciplinary
RCT beneficial Hysteroscopy
procedures Endometrial injury IU administration of
autologous PBMC Peripheral
blood mononuclear cell Blastocyst transfer Assisted hatching Salpingectomy for
tubal disease
RCT Not or may not beneficial Aspirin heparin IVIG intralipid does not
have a clear impact on ttt outcome
Co cultures sildenafil transfer of six embryos natural IVF and PGS await further clinical assessment
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-
Wednesday May 3 2023
Thank you
- Slide 1
- Objectives
- Definition
- Slide 4
- Slide 5
- Recurrent implantation failure vs Recurrent IVF failure
- What is implantation rate
- Is chemical pregnancy considered as implantation failure
- The common defendants
- Slide 10
- Slide 11
- Pregnancy depends on implantation of a developmentally competen
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Does it affect IVF results
- Options for management
- Slide 28
- Complications of salpigectomy
- Slide 30
- Endometrial scratching before IVF
- In women with RIF inducing local injury to the endometrium in
- Slide 33
- Inadequate endometrium
- Causes of refractory endometrium
- US assessment of endometrial receptivity of clinical significan
- Slide 37
- Slide 38
- Slide 39
- Endometrial pattern
- Chronic endometritis
- Clinical relation between RIF and CE
- Diagnosing CE
- Slide 44
- Criteria proposed by Cicinilli et al 2005 to establish the dia
- Prehysteroscopic diagnosis
- Management of refractory endometrium
- Medical therapeutic strategies
- Slide 49
- Slide 50
- Q does estrogen addition as an adjuvant to progesterone in the
- Estrogen increase clinical pregnancy rate but its role in man
- HCG injection in the proliferative phase
- Slide 54
- Granulocyte-colony stimulating factor (G-CSF)
- Slide 56
- Low-dose aspirin
- After wide application of doppler US and assessment of subendom
- Slide 59
- Slide 60
- Administration should be suspended before ET
- Nitroglycerin
- Slide 63
- Sildenafil
- Slide 65
- Slide 66
- GnRH analogues
- Slide 68
- Luteal phase GnRH agonists in cases of RIF
- Slide 70
- Slide 71
- Slide 72
- Immunological implantation dysfunction
- Slide 74
- Slide 75
- Slide 76
- Intralipid 20
- Slide 78
- Slide 79
- Role of IVIG
- Role of steroids
- Empiric use of Aspirin
- Anticardiolipin antibodies
- Slide 84
- Slide 85
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- The embryo
- Is morphological grading is sufficient
- Embryonic interventions that may improve IVF success
- Slide 93
- Slide 94
- Q Is blastocyst transfer is a successful treatment in cases o
- Slide 96
- Slide 97
- Slide 98
- Slide 99
- Guideline
- Slide 101
- Slide 102
- Slide 103
- Slide 104
- Slide 105
- Slide 106
- Slide 107
- IMSI
- Slide 109
- Slide 110
- ET Technique as a cause of IVF failure
- Is FET cycles is an easy and good alternative
- Vitrification is Ultra-Rapid freezing method the keep the biolo
- One in 4 females has displaced window of implantation so need P
- Slide 115
- Slide 116
- Slide 117
- Slide 118
-