RIF DR.FIROUZABADI JUNE 2022 - PowerPoint Presentation

Slide1

RIF

DR.FIROUZABADI

JUNE 2022

Slide2

DEFINITION

Three previous IVF-ET failed attempts’ is the most com-

monly

used

threshold

A minority

but

prefer

diagnoses RIF after

only two

previous IVF-ET failed

attempts

Some

authores

defined

RIF as the failure after the transfer of at least

four good-quality embryos

within

minimum

three

fresh or frozen cycles under 40 years of

age

Slide3

Slide4

An 

assisted reproductive technology

 (ART) cycle has four components: ovarian stimulation to provide multiple 

gametes

, laboratory procedures for 

fertilization

 and embryo development, 

embryo transfer

, and 

luteal phase

 

support.

Although a poor response to ovarian stimulation is most often caused by decreased 

ovarian reserve

 or, less commonly, by

inadequate

stimulation

, there are many possible reasons for failure in the remaining steps

Among these,

embryo

 

aneuploidy

 (EA) stands out as

the most

common cause of ART failure

. Embryo aneuploidy is the leading cause of embryo developmental arrest, implantation failure, and miscarriage

Slide5

Implantation is one of the most critical steps

in reproduction .

Successful implantation requires

a

competent embryo( blastocyst)

,

a

receptive

endometrium

and a

synchronized dialogue

between the maternal

and embryonic tissues.

INCIDENCE ;10%

approximately

50%

of

RIF patients may ultimately not complete their family

goals

F1000Research 2020 (Diagnostic and therapeutic option in RIF)

Current opinion 2020 (Determining diagnostic criteria and causes of RIF)

Slide6

DIAGNOSIS and CAUSES

Careful clinical evaluation prior

to

assisted

reproduction can uncover many treatable causes, including

thyroid

dysfunction

,

submucosal

myomas

, and

tobacco use

. The

more-subtle

causes

often require a more-targeted assessment

.

Endometrial diseases, such as

polyps

, submucosal

fibroids

, intrauterine

synechiae

, chronic

endometri

-

tis,

endometrial

microbiota

, unexplained

thin endo-

metrium

and

fluid in the endometrial cavity

, may

play a role in the

etiopathogenesis

of RIF.

Slide7

Uterine evaluation

Ultrasound :an

endometrium

that does not sufficiently thicken

,or is echogenic ,predicts

a

lower

chance

of embryo

implantation

Most, if not all, centers utilize at least one form of uterine

cavity evaluation prior to embryo transfer.

Hysterosalpingogram

(HSG),

saline-infusion sonography

(SIS),

and

hysteroscopy

are

all accepted tools for cavity assessment

.

Additionally,

the

use

of hysteroscopy in patients with prior failed transfers

was associated

with an increase in clinical pregnancy,

whether

or

not pathology was detected, perhaps owing to a benefit

of

endometrial

injury

and repair

Slide8

Hysteroscopy may

raise suspicion

of chronic

endometritis

Features such

as

micropolyps

and

hyperemic

or edematous endometrium

may be identified on hysteroscopy,

and these may raise suspicion for otherwise subclinical CE

.

For these reasons,

we strongly

support the

use of endometrial sampling as part of the evaluation of

all

RIF patients

.

TUBES :evaluation for presence of

hydrosalpinx

Laparoscopy :only for those patients who are in high risk for endometriosis ( positive mi RNA )

Slide9

Another tool for evaluation of uterine component is

ERA

All findings

indicate that currently it is yet early to decide

that the ERA test has a definitive effect in RIF cases

.

Observational study showed that 25% of RIF patient have

abnormal

ERA

in comparison to control group(15%)

ENDOCRINE CAUSES:

the upper limit of

Thyroid Stimulating

Hormone (TSH)

values in infertile couples is

recommended

to be below 2.5

mIU

/l

.

ATPO

positivity

might have negative effects on miscarriage

and live

birth rates.

Slide10

Immunological factors

Even though the role of immune system in RIF

is controversial

, natural killer (NK) cells, killer

immunoglobulin-like

receptors (KIRs), human

leukocyteantigen

(HLA) molecules, T-helper cells (

TH1–TH2) and leukemia

inhibitory factor have also been

investigated

.

Placental

formation results from

the interaction

in between maternal KIRs expressed

from uterine

NK cells and fetal HLA-C molecule

originated from

extravillous

trophoblasts

Slide11

Rising level of Th1/Th2 may causes rejection of placenta But only in abnormal immunological risk factors treatment is logical

APS

:despite confirmed role of thrombophilia in preventing placentation ,no

definit

data are available on association of APS with RIF

Slide12

Genetic factors

Abnormality in oocyte , sperm , parental chromosomes and embryo

Some

authors believe

sperm DNA

fragmentation has negative effect on IVF

The

prevalence of

parental chromosome

abnormalities related with

RIF patients has been reported as 2.5% in the

literature

PGT-A

:

varying results have been reported in

the literature about PGT-A

Slide13

Slide14

Treatment

Intrauterine HCG

:

A recent systematic review concluded that

hCG

improved clinical

pregnancy rates and live birth rates while reducing

miscarriage (

SUGGEST AS CLINICAL RESEARCH

)

PRP

:

(As an anti-inflammatory and regenerative factor) Several small

, observational

studies and several clinical trial

have demonstrated a positive

impact of

intrauterine infusion of PRP on

endometrial thickness

and

pregnancy rates

Slide15

LETROSOL

:

It may be effective in occult endometriosis and

demonestrated

causes an increase in integrin level

Rx for CE

:

Especially in RIF, CE has been reported at an incidence of

ranging from

14 to 30% with decreased pregnancy success

rates

CE

is considered to affect endometrial

receptivity via

establishing a

dysbiotic

endometrial environment

featured by

dense lymphocyte populations along with a shift

toward inflammatory

cytokine profiles

(

Th1/Th17)

Slide16

GCSF:

most of the meta-analyses have showed a positive impact of G-CSF administration in case of RIF. But level of evidence is low

.

GH

:

shown to promote the expression of critical factors for receptivity such as VEGF, LIF, and β3 integrin

subunit.

Slide17

IVIg

treatment

:

for RPL and RIF has Level II evidence for medical application: Evidence from a meta-analysis of all relevant randomized controlled trials. Large RCTs are warranted to identify which subcategory of patients benefit the most from IVIG treatment

.

Recommended:karyotype

, PGT-A

Limmited

to

research:immunologic

therapy , ERA, LMWH

Not

recommended:

hystero

if U/S is normal ,thrombophilia ,DFI ,screening for

C.endometritis

,scratch ,aspirin

Slide18

Rate of true recurrent

implantation

failure

is low

Fertility Sterility 2021 A large retrospective cohort study

They

sought to establish

the incidence

of RIF in women who have an

anatomically

normal uterus

and are undergoing consecutive

euploid

single

embryo transfers

RIF rates after three

FE-SETs (

frozn

euploid

)

seems to have an incidence of <5%.

These findings challenge

the

publications

These results suggest

that most RIFs are of

embryonic origin

, which can

be minimized

by transferring

euploid

embryos

Slide19

The mean age of the patients included in the study was of 35.4 years. The sustained

implantation rates

of the first, second, and third FE-SET were 69.9%, 59.8%, and 60.3% per transfer, respectively. The cumulative sustained implantation rate after up to three consecutive FE-SET was 95.2%. The

live birth rate

s after the first, second, and third FE-SET were 64.8%, 54.4%, and 54.1% per transfer, respectively. The

cumulative live birth rate

after up to three consecutive FE-SET was 92.6%. The

miscarriage

rate after observing a positive heartbeat was not different between the first (7.2%), second (8.8%), and third (12.7%)

FE-SET

A total of 4,429 women who met the inclusion criteria were

included in the study

.

PGT-A ,by CGH and NGS

Slide20

Preimplantation genetic diagnosis

(PGD)

in the human was

introduced in the late

1980s

for fertile couples at risk of

transmitting

X chromosome-linked

diseases

to their

children

The initial technique was FISH with its limitations

Slide21

in 2007 a multicenter, randomized, double-blind trial comparing

three cycles of IVF with and without genetic screening in women

aged 35-41 was published: this was the first study to demonstrate

that PGT-A using FISH technology was

inefficient.

Few years later,

same authors

confirmed the finding publishing a meta-analysis of

RCTs .

And after that ASRM and ESHRE discouraging use of PGT-A

These negative result was mainly due to

FISH

and use of

day 3 embryo

,when the chance of mosaic embryo is high (30%)

Also cleavage stage biopsy has

negative impact

on embryo viability

Slide22

Following the discouraging results associated with FISH technology and day-3 embryo biopsy,

scientists in

the field began developing a new technology for PGT-A.

The changes

include mainly two factors: the genetic testing with

comprehensive

chromosome screening (CCS)

methods with the

ability

to simultaneously evaluate the ploidy status of all

23 chromosome

pairs, and the shift of embryo biopsy from

cleavage stage

to

trophectoderm

biopsy (TEB) at blastocyst stage

Slide23

Slide24

In conclusion our study of a large cohort of repeated FE-SETs in women whose endometrium was sonographically

normal, seriously

questions the existence of RIF due to endo-

metrial

effects

.

Slide25

Evaluation of the endometrial receptivity assay and the PGD for aneuploidy in overcoming RIF

J of assisted reproduction and genetics 2020

An observational retrospective study

Inclusion

critera

:ET with 3 good quality embryo in different single

freez

or fresh transfer

Exclusion

driteria

: Patients

with an

abnormal

karyotype such as translocation or an inversion carrier

and with

thrombophilia, either congenital or acquired

,

submucose

myoma

, polyp, previous highly difficult ET ,previous PGT-A

Slide26

M-RIF (MODERATE) 3 or more failure (2110 PT.)S-RIF 5 or more failure( 488 PT.)

The ERA may

personalize the

timing of ET, synchronizing embryonic development

with the

endometrial WOI of the

patient

Chromosomal analysis was performed by array comparative

genomic hybridization (

aCGH

) or next-generation sequencing

(NGS).

Slide27

The results suggest that PGT-A could be a useful tool for

assessing chromosomal viability in RIF patients to avoid the

transfer of aneuploidy embryos in

M-RIF

. In

S-RIF,

the use of

PGT-A does not improve ongoing pregnancy rate, although

this group included a small number of embryo

transfers

Also this study

determined that the ERA test does not benefit RIF

patients.

The use of PGT-A yielded a

better implantation rate per transfer (45.9%) than standard IVF

(35.9%)

with Implantation

rates per transfer were not improved over

standard rates

by ERA

,, and ERA+PGT-A,

Slide28

chromosomal screening should be considered for M-RIF patients

to overcome

infertility

This

difference

perhaps reflects the small sample size of S-RIF

patients

but could also reflect a different cause of implantation

failure, potentially related to endometrium quality

Slide29

Performance of PGT for aneuploidy in IVF cycles for patient with advanced maternal age, repeated pregnancy loss, and RIF

(2019

taiwanian

J.)

A retrospective study

was conducted between November

2012 and January 2015 by using the data of 296 couples undergoing

controlled ovarian stimulation for IVF with preimplantation genetic

testing for aneuploidy (

PGT-A) by

CGHa

87 AMA /82 RIF/ 82 RM / 45 OD young age as control group

Because aneuploidy is a leading cause of

implantation failure, selection of a

euploid

embryo has been

hy

-

pothesized

to significantly improve the IR. In this study, the LBRs in

the high-aneuploidy groups (AMA, RIF, and RM) might be elevated

to as high as those in young age control group (OD) through PGT-A

of blastocysts with

aCGH

Slide30

Conclusion

THIS study

showed that

improved LBR

can be

obtained

following blastocyst biopsy,

vitrification

, and aneuploidy

assessment by using

aCGH

in IVF cycles for patients with a

potentially

high rate of aneuploidy, especially patients with AMA.

However

, a large RCT is necessary to affirm

this

findings.

Slide31

The ESHRE PGD Consortium defined RIF as “more than 3 embryo

transfers with high quality embryos

or the

transfer of

no less than 10 embryos

in multiple

transfers

The embryo itself

is thought

to be

responsible for 30–50%

of

RIF

Transfer of

euploid

embryos reduces implantation

failures

, and RIF is an indication for preimplantation

genetic testing

for aneuploidy (PGT-A

)

1995 (FISH)

2003 FISH for PGD

Slide32

Since that several research reported different result and finally ACOG and ESHRE hold PGT-A for RIF AT 2009

A

pilot study 2014

determines that the array CGH-based PGS with

single

euploid

blastocyst transfer is a successful strategy for

RIF

Then

ARSM committee opinion in 2018

mentions

for the first time that PGT-A for prior implantation

failure

must be addressed by further

research

Moreover,

a recent

study concludes that live birth rate can be

improved using

array CGH-based PGT-A with blastocysts transfer

during

the IVF cycles for patients with a high rate of aneuploidy

Slide33

Specifically, NGS

allows

for identifying and screening embryos with

euploidy

,

aneuploidy

and chromosomal

mosaicism

NGS may represent a valuable supplement to

the current

aneuploidy screening approaches for RIF

Slide34

METHOD

A total of 265 couples with a history of RIF were recruited

into this retrospective study. In our program,

RIF

was defined

as the absence of implantation after

two consecutive

cycles of

IVF, ICSI or frozen embryo replacement, where the

cumula

-

tive

number of transferred embryos was

≥ 4 for cleavage-stage

embryos and

≥ 2 for blastocysts

, and all embryos were of good

quality and at appropriate developmental

stage

Slide35

Thereafter, the study population was divided into two groups according to maternal

age

A: 184 pt. Age <38 with 221 oocyte retrieval cycle /180 NGS cycle

And 91

pt

had 102 transfer

B : 81 PT age>38 125 oocyte retrieval cycle /70 NGS CYCLE and 19 patient had 23 transfer

ICSI

was performed

to ensure the high fertilization rates and to avoid

any contamination caused by the attachment of residual

sperm-derived DNA to the zona

pellucida

at

biopsy

Embryos were cultured to the blastocyst stage under assisted

hatching, followed by

trophectoderm

biopsy on day 5 or day

6.

Later

Slide36

For the cost-effectiveness,

no more than 6

embryos

were analyzed at one time for each patient

.

Only patients

obtaining

euploid

embryos

were eligible for

transfer.

The policy

was to transfer

one

euploid

embryo per

patient in a hormone replacement cycle

Slide37

Result

Altogether

265 RIF patients

completed

346 oocyte retrieval

cycles in this study; of them,

trophectoderm

biopsies

were

available in

250

cycles

The

advanced age

group had significantly shorter duration of

stimulation

, less oocytes retrieved, less MII oocytes, less

oocytes fertilized

, less fertilized oocytes that cleaved, and less

blastocysts than those of the younger age group. No

significant

difference was detected in the dose of FSH

used between

two

groups

The

component of

aneuploid

embryos

was significantly higher in advanced age group than

in younger

age group

Slide38

Patients in advanced

age group

obtained an average of

0.43

(35/81) embryos

eligible

for transfer only, while those in

younger age

group

received

an average of

1.63

(300/184) embryos for

transfer

However, differences in pregnancy rate (43.5

vs 64.7

%), clinical pregnancy rate (39.1 vs 48.0%),

implantation

rate (39.1 vs 51.0%), and miscarriage rate (4.3

vs 7.8

%) per transfer between two groups were not

statistically

significant

Slide39

Moreover, plenty of studies reveal that the

euploid

rate of RIF

patients is

lower

than

that in other infertile patients.

The embryonic ploidy

directly

affects the embryo implantation

and the successful de-

velopment

of those embryos into healthy babies

.

Traditionally

, embryos for transfer are selected based

on the

morphology alone

. However, morphology is a poor

predictor of embryo

euploidy

, while aneuploidy often

shows no

morphological manifestation, and the

chromosomally chaotic

embryos may appear normal morphologically

Slide40

The high aneuploidy frequency in RIF patients,together

with the poor predicting capacity of

traditional morphology

, has promoted the

introduction of PGT-A

in RIF

management by determining embryo

euploidy

before transfer

to the uterus

.

Biopsy at advanced stage

of embryonic development (like

trophectoderm

biopsy) is more resilient to

technical

manipulation

than biopsy at cleavage stage. In addition,

blastocysts are

robust

compared with those at earlier embryonic

stages, which

can better tolerate the insult of biopsy than the

cleavage-stage embryos

Slide41

Conclusion

T

his

study argues that for RIF patients

of advanced

age with

euploid

embryos, the

NGS-based

PGT-A of

trophectoderm

biopsy

increases the chance of achieving

a successful

pregnancy. NGS-based PGT-A of

trophectoderm

biopsy

appears to be a reliable management for them.

However, these findings should be further validated in a

well-designed randomized controlled

trial

Slide42

Going through IVF with PGD or PGT-A can be very stressful;

patients are emotionally vulnerable and after several failures are

often willing to trial new options. An

accurately counseling

is

absolutely crucial, patients must be informed about the

advantages

and

disadvantages

of this technique, and they need

to understand

to use of the genetic screening and its clinical

efficiency .

Lastly, there are currently no data

on

long-term effects

on the children born after embryo biopsy, and will

be necessary

to perform such study on long-term

follow-up

of these

babies.

Slide43

Normalization of endometrial histopathology and endometrial NK cells concentration predict successful pregnancy in repeated implantation failure

Slide44

The high association between Chronic

Endometritis

(CE) and RIF is established (14-31%), as well as unknown etiologies (28%) and recurrent

Pregnancy loss

, the literature agrees that the presence of multiple endometrial stromal plasmatic cells (PCs) is the most specific and sensitive finding in this pathology

Endometrial immunohistochemistry (

enIHQ

) by CD138, a cell surface proteoglycan that is expressed on plasma cells, improves diagnostic accuracy

Slide45

Endometrial therapy

We instructed all the patients to change their eating habits to a Mediterranean diet, under nutritional control as well as to refrain from toxic substances, especially

nicotine

, add physical activities to their routines and take vitamin supplements. We prescribed Glycine 100 mg/day associated with Vitamin E 300 mg,

Vit

. B6 100 mg,

Vit

. A

10.000 UI and

Vit

. D 300 IU/day. When a germ was found, we prescribed the specific antibiotic therapy for at least 30 days.

Slide46

The cycle stage impacts PC prevalence, the

endometrial

sample obtained in the proliferative phase shows 50% higher PCs than in the secretory phase

Over an initial population of n=74 cases of RIF in

oocyte

donation in the period 2008-2016, we analyzed 66 cycles/patient

Of the 66 cycles selected, the patients’ mean age was 39.46±4.91 (26-56) years, length of sterility 10(6 years, and a number of previous cycles ART (4±2.24)

The evaluation by endometrium biopsy in pre and post-treatment was performed

We used all the samples to investigate the lymphocyte population by CF and abnormal patterns by histopathology.

Slide47

When we couldn’t find a specific germ, we used

oral Doxycycline

(100 mg, twice per day) for 14 days, continuing with a combination of

metronidazole

and ciprofloxacin (both drugs in 500 mg, twice per day, 14 days) and ending with

Clarithromycin

(1 gr/day for 12 days). When there was no remission of the inflammatory process in the post-treatment biopsy, we repeated the scheme above and added Linezolid (600 mg/day orally for 10 days), and

performed

a new

enHP

. For mycoplasma relapses, we

prescribed

minocycline

(100 mg, twice per day, 12 days). In patients with elevated

enNK

, we added

methylprednisone

in a dose of 2 mg/day orally. In high

enNK

concentrations and/or thin endometrium, we indicated intrauterine

instillations

of Granulocyte Colony Stimulating Factor (G-CSF) (

Filgastrin

), in doses of 300 micrograms at the beginning of progestin supplementation in replacement cycles. We used a second dose subcutaneously five minutes after the blastocyst transfer. Finally, in cases with increased uterine contractibility, we used an oxytocin inhibitor

(

Atosiban

),

at a dose of 6.75 mg per slow intravenous administration, prior to transfer.

Slide48

Thanks for your attention