DEFINITION Three previous IVFET failed attempts is the most com monly used threshold A minority but prefer diagnoses RIF after only two previous IVFET failed attempts Some ID: 932672
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Slide1
RIF
DR.FIROUZABADI
JUNE 2022
Slide2DEFINITION
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
Slide3Slide4An
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
Slide5Implantation 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)
Slide6DIAGNOSIS 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.
Slide7Uterine 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
Slide8Hysteroscopy 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 )
Slide9Another 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.
Slide10Immunological 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
Slide11Rising 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
Slide12Genetic 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
Slide13Slide14Treatment
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
Slide15LETROSOL
:
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)
Slide16GCSF:
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.
Slide17IVIg
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
Slide18Rate 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
Slide19The 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
Slide20Preimplantation 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
Slide21in 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
Slide22Following 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
Slide23Slide24In 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
.
Slide25Evaluation 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
Slide26M-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).
Slide27The 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,
Slide28chromosomal 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
Slide29Performance 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
Slide30Conclusion
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.
Slide31The 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
Slide32Since 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
Slide33Specifically, 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
Slide34METHOD
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
Slide35Thereafter, 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
Slide36For 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
Slide37Result
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
Slide38Patients 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
Slide39Moreover, 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
Slide40The 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
Slide41Conclusion
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
Slide42Going 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.
Slide43Normalization of endometrial histopathology and endometrial NK cells concentration predict successful pregnancy in repeated implantation failure
Slide44The 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
Slide45Endometrial 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.
Slide46The 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.
Slide47When 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.
Slide48Thanks for your attention