recurrent implantation failure
DESCRIPTION
Recurrent implantation failureTRANSCRIPT
Recurrent implantation
failure Prof. Aboubakr Elnashar Benha University Hospital, Egypt
Aboubakr Elnashar
Contents 1. Introduction Definition, Incidence, Impact
2. Etiology
3. Investigations
4. Treatment
Conclusion
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1. Introduction Definition No universally accepted definition
Failure of implantation
After 3 consecutive IVF attempts,
after transfer of at least 4 good-quality embryos
in a woman under the age of 40 ys (Simon and Laufer, 2012; Coughlan et al, 2013).
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Failure of implantation
after 2 consecutive cycles
after transfer of at least 4 good-quality embryos
or 2 blastocysts (Polanski et al, 2014)
Not the same as R IVF F.
subgroup of R IVF F
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Incidence
10% of the cycles
(Margalioth et al, 2006).
Impact
Distress to couples
Frustration to doctor
Increases the cost of the procedure
Management
Major challenge to clinicians and embryologists.
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2. Etiology I. Endometrial
II. Gamete/embryo
III. Multifactorial
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I. Endometrial factors
1. Anatomic causes: Polyp, fibroid, adhesion, septum
2. Impaired function
Thin endometrium
Altered expression of adhesive molecules
3. Thrombophilia
4. Immunological factors
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II. Gamete/embryo factors 1. Parental chromosomal anomalies
2. Poor-quality oocyte
3. Poor-quality spermatozoa
4. Zona hardening
5. Suboptimal culture conditions
6. Suboptimal embryo quality
7. Suboptimal ET
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III. Multifactorial
1. Endometriosis
2. Hydrosalpinges
3. Suboptimal ovarian stimulation
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3. Investigations
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Investigations for endometrial causes: (Simon and Laufer, 2012)
1. Hysteroscopy: intra-uterine pathology
2. TVS/ MRI: Structural uterine anomalies
3. HSG: hydrosalpinges
4. Hormone profile: Endometrial defects secondary to
endocrine aberrations
5. Endometrial Biopsy: uNK cells
6. Blood tests for thrombophilia and antiphospholipid antibodies.
7. All tests: normal: test for HLA similarity Aboubakr Elnashar
Investigation of embriologic factors (Simon and Laufer, 2012, Coughlan et al, 2013)
1. Ovarian reserve tests
basal FSH, AMH, AFC
to exclude any significant compromise of ovarian
function: help in the counseling.
2. Sperm DNA fragmentation:
Sperm Chromatin Structure Assay (SCSA):
Sperm chromatin dispersion test (SCD)
DNA fragmentation index
>27%: RIF (Larson et al.,2000; Larson-Cook et al., 2003)
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Damaged DNA : no halo.
Intact DNA: chromatin dispersion halo
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3. Karyotype
to rule out structural anomalies of chromosomes.
2.5% (Stern et al., 1999)
4. If a structural anomaly:
preimplantation genetic diagnosis
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4. Treatment Individualized Multidisciplinary
Experienced fertility specialist
Senior embryologist
±Reproductive surgeon
Local protocol
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I. Endometrial 1. Correction of anatomic factors
Hysteroscopic correction of uterine cavity
pathology (Demirol and Gurgan, 2004).
Removal of fibroids
Distorting the uterine cavity
Intramural ≥5cm (Donnez and Jadoul, 2002).
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2. Improvement of endometrial function
a. Treatment of thin endometrium
To improve uterine blood
low-dose aspirin (Weckstein et al., 1997)
vaginal sildenafil (Sher and Fisch, 2002)
Freeze all embryos (when the endometrium <7
mm) and transfer them after stimulation with high-
dose estrogens
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Vaginal micronized estradiol (Tourgeman et al., 2001)
Antifibrotic: pentoxifylline (Trental) and
high-dose vitamin E (Ledee-Bataille et al., 2002)
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b. Endometrial sctatching
When:
cycle preceding the actual treatment cycle. (Friedler et al., 1993; Barash et al., 2003; Raziel et al., 2007; Zhou et
al., 2008). 7 days prior to the onset of menstruation,
immediately before the start of ovarian stimulation
for IVF tt.
In the follicular phase of the index cycle : no
benefit (Karimzade et al., 2010; Zhou et al., 2008).
Not on the day of OR:
significantly reduce CPR (Nastri et al, 2012)
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How
biopsy/scratch or hysteroscopy: CPR doubled. (Raziel et al., 2007 ; Narvekar et al, 2010)
CPR: twice as high with biopsy/scratch as
opposed to hysteroscopy (Potdar et al, 2012) (2 syst reviews: Potdar et al, 2012; El-Toukhy et al, 2013)
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(A) First, the pipelle sample is inserted until it reaches the fundus.
(B) The inner plunger is withdrawn to apply a suction force to the endometrial cavity.
(C) Endometrial scratch of the superficial layer of the endometrium is performed with
the use of a ‘hoovering’ movement, combining a rotational and in-and-out movement
of the pipelle sampler several times. Aboubakr Elnashar
Mechanisms:
1. Induce decidualization of the endometrium
2. Provoke wound healing, involving secretion
cytokines and growth factors (Li and Hao, 2009).
3. Recruit stem cells to the endometrium, creating a
partially new endometrium free of epigenetic defects (Taylor, 2004; Du and Taylor, 2007).
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3. Thrombophilia Thrombophilia: LMWH
Thrombophilic trait: prophylactic dose of LMWH:
improve IVF outcome (Bohlmann et al, 2011; Qublan et al, 2008).
Antiphospholipid antibody syndrome:
Empirical treatment:
LMWH, aspirin, or corticosteroids:
Not effective
Not advocated (Seshadri et al, 2011; Berker et al, 2011).
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4. Immunotherapy
IVIG
Although data showing some benefit on ART
outcome.
SR does not support
{paucity, or poor quality of, the evidence}. (SR: Polanski et al, 2014)
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Intralipid
Controlled, large-scale, confirmatory studies
are necessary to prove efficacy before it can be
recommended for routine use. (Shreeve; Sadek, 2011)
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Intrauterine administration of autologous
peripheral blood mononuclear cells (PBMC)
Freshly isolated from patients: effectively
improves embryo implantation (Yoshioka et al, 2006; Okitsu et al, 2011 Chen et al, 2011)
{1. Evoke favourable inflammatory reactions : producing cytokines 2. secrete proteases: regulate endometrial function}
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II. Treatment of the embryos
1. Chromosomal abnormality Preimplantation genetic screening
can clarify the reason for RIF. (Caglar et al. ,2005)
significantly lowered live birth rates in RIF (Meta-analysis of RCT, Mastenbroek et al,2011)
does not improve the live birth rates RIF
(ASRM, ESHRE, 2010).
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2. Sperm DNA fragmentation a. Oral antioxidant
reduce the incidence of sperm DNA fragmentation (Greco et al., 2005 ; Isidori et al., 2006).
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b. Select spermatozoa with low levels of DNA
damage from the ejaculated semen samples (Sakkas and Alvarez, 2010).
i. Annexin-V columns:
reduce the percentage of spermatozoa with DNA fragmentation as measured by the TUNEL test
ii. Sperm hyaluronic acid binding: (Jakab et al., 2005; Said et al., 2005, 2006).
iii. Onfocal light absorption scattering
spectroscopy (CLASS) technology
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iv. Intracytoplasmic morphologically selected
sperm injection (IMSI)
high-magnification microscope (6000x), to identify spermatozoa devoid of surface vacuoles (Bartoov et al., 2003).
The only confirmed indication for IMSI is RIF. (MA: Boitrelle et al, 2014)
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c. Use of testicular spermatozoa
{sperm DNA damage is lower in the seminiferous tubules as compared with the cauda epididymis and ejaculated spermatozoa} (Greco et al., 2005; Steele et al., 1999; Suganuma et al., 2005)
Significant increase in PR (Greco et al., 2005b; Weissman et al., 2008)
reduction of miscarriage rate (Borini et al., 2006)
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3. Assisted hatching
Significant increases CPR in RIF (Three RCTs: Chao et al., 1997; Magli et al., 1998; Nakayama et al.,
1999; Metaanalysis, Martins et al, 2011)
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4. Suboptimal culture a. Co-culture
Homologous endometrial cells (Jayot et al., 1995; Eyheremendy et al, 2010)
49% PR in RIF. (Spandorfer et al. ,2004)
Most IVF units do not have facilities and experience
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b. Blastocyst transfer
Significantly higher CPR (Guerif et al., 2004; Levitas et al., 2004).
{Improved embryo selection and uterine receptivity}
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5. Improving ET
Essential in each cycle and must be reconsidered
in RIF.
Atraumatic, US guided
Embryos deposited in the mid uterine cavity (Sallam, 2005)
Avoidance of blood, mucus, bacterial
contamination, touching the fundus, and excessive
uterine contractions
Trial transfer, filled bladder, soft catheters (Schoolcraft et al, 2001)
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Fibrin glue
doubled CPR in RIF (Bar-Hava et al. ,1999).
Transfer large number of embryos
significant increase in CPR in RIF (Azem et al.1995)
No comparative study.
Sequential embryo transfer
Interval double ET (on days 2 and 4 or 5):
improves CPR in RIF (Loutradis et al, 2004; Almog et al., 2008)
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Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive
or not)
pET performed on the day designated by the
ERA: 50.0% PR and 38.5% IR (Ruiz-Alonso et al, 2013).
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III. Multifactorial treatment options Lifestyle changes Smoking
Alcohol consumption
BMI
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1. Salpingectomy of hydrosalpinges
CPR and live birth rates: doubled (Strandell et al., 1999; Cochrane sys rev Johnson et al., 2004).
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2. Treating endometriosis
GnRHa for 3–6 months before ART: significantly
increases CPR (Surrey et al., 2002).
increased CPR by 4-fold (Sallam et al., 2006).
Endometrioma:
No benefit of removal before IVF (Garcia-Velasco et al., 2004; Wong et al., 2004),
Surgery ± deleterious for ov reserve.
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3. Danazol
significantly increased CPR (40 vs 19.5%) (Tei et al., 2003).
{Immunosuppressive effects
increase receptivity of the endometrium
upgrade the endometrial αVβ3 integrin.} (Hill et al., 1987).
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4. Tailoring the stimulation protocols GnRHan protocols:
improved blastocyst quality and pregnancy
outcome after RIF with GnRHa protocols (Takahashi et al. ;2004).
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Addition of LH
1. Poor responders to FSH stimulation in down-
regulated cycles (Phelps et al., 1999; Surrey and Schoolcraft, 2000).
2. Above 35 ys (Balasch et al., 2001; Marrs et al.,2004; Phelps et al., 1999).
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Natural cycle
particularly with high uNK cell count (Kadoch, 2003, Ledee-Bataille et al., 2004).
No RCT to prove that changing any stimulation
protocol can improve treatment outcome.
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Conclusions Many known and unknown reasons for RIF, and
we do not have the tools to diagnose in each case
the exact cause.
After failure of 2 or 3 transfers of good-quality
embryos in a unit with CPR of at least 30%, one
should take some special measures.
The management of RIF should be
individualized
multidisciplinary
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RCT: beneficial
Hysteroscopy procedures
Endometrial injury
IU administration of autologous PBMC
Blastocyst transfer
Assisted hatching
Salpingectomy for tubal disease
Aspirin, heparin, IVIG, intralipid does not have a
clear impact on tt outcome.
Co cultures, sildenafil, transfer of six embryos,
natural IVF, and PGS await further clinical
assessment.
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