Assessment and treatment of repeated implantation failure (RIF)

Repeated implantation failure (RIF) is determined when embryos of good quality fail to implant following several in vitro fertilization (IVF) treatment cycles. Implantation failure is related to either maternal factors or embryonic causes. Maternal factors include uterine anatomic abnormalities, thrombophilia, non-receptive endometrium and immunological factors. Failure of implantation due to embryonic causes is associated with either genetic abnormalities or other factors intrinsic to the embryo that impair its ability to develop in utero, to hatch and to implant. New methods of time-lapse imaging of embryos and assessment of their metabolic functions may improve selection of embryos for transfer, and subsequent outcomes for IVF patients, as well as for those diagnosed with RIF. This review discusses the various causes associated with RIF and addresses appropriate treatments.     

Maternal and paternal carriage of the annexin A5 M2 haplotype: a possible risk factor for recurrent implantation failure (RIF)

ObjectiveThis study was carried out to determine the potential role of the M2/ANXA5 haplotype as a risk factor for recurrent implantation failure (RIF). Carriage of the M2/ANXA5 haplotype that induces prothrombotic changes has been implicated in failure of early pregnancies and placenta-mediated complications (preeclampsia, IUGR, preterm birth).Material and methodsIn the present case control study, 63 couples (females and males) with RIF presenting for IVF/ICSI to the Fertility Center of [masked] were analyzed. RIF was defined as ≥ 4 consecutive failed ART-transfers of ≥ 4 blastocysts or ≥ 8 cleavage-stage embryos of optimal quality and maternal age ≤ 41. Fertile female controls (n = 90) were recruited from the same center. Population controls (n = 533) were drafted from the PopGen biobank, UKSH Kiel.ResultsCouples carrying the M2/ANXA5 haplotype turned out to have a significantly increased relative risk (RR) for RIF. Compared with female fertile controls, RR was 1.81 with p = 0.037 (OR 2.1, 95%CI 1.0–4.3) and RR was 1.70, with p = 0.004 (OR 2.0, 95%CI 1.2–3.1) compared with population controls (15.4% M2 carriers). Male partners were comparable with RIF females for M2/ANXA5 haplotypes (28.6% vs. 23.8%, p = 0.54). RIF females compared with population controls had a RR of 1.55 (p = 0.09) and RIF males compared with population controls had a RR of 1.9 (p = 0.01). Couples with ≥ 7 failed transfers showed a RR of 1.82 (p = 0.02) compared with population controls.ConclusionOur findings suggest that maternal as well as paternal M2/ANXA5 haplotype carriages are risk factors for RIF. These results allow new insights into the pathogenesis of RIF and might help to identify relevant risk groups.     

反复胚胎植入失败和流产与子宫内膜免疫因素

胚胎着床及发育是一个母-胎相互识别、相互适应的复杂过程。在此过程中,滋养细胞表达胚胎抗原并分泌细胞因子,逃避母体免疫系统的攻击,母体蜕膜特征性免疫细胞的富集形成母-胎界面独特的免疫微环境,从而有利于胚胎着床及发育。虽然近年来体外受精-胚胎移植（IVF-ET）的成功率已有很大提高,反复种植失败（RIF）仍是困扰辅助生殖技术发展的难题。胚胎作为同种异体移植物不被母体免疫系统排斥是妊娠建立和维持的关键,母-胎免疫调节异常可致复发性流产（RSA）,给患者夫妇身心及经济均带来极大负担。随着生殖免疫学的发展,子宫内膜免疫因素在RIF和RSA发病中的作用日益受到关注,针对性的免疫治疗也在RIF和RSA的治疗方案中扮演着越来越重要的角色。文章就RIF和RSA子宫内膜免疫因素的分子病理机制及其免疫治疗的当今认识进行阐述,以期为未来的科学研究及临床治疗提供参考。     

Autologous platelet-rich plasma improves the endometrial thickness and live birth rate in patients with recurrent implantation failure and thin endometrium

PurposeThe aim of this study was to evaluate the effects of intrauterine platelet-rich plasma (PRP) infusion on endometrial thickness and pregnancy outcomes in a population of patients with either recurrent implantation failure (RIF), thin endometrium (TE), or both (RIF + TE)MethodsThis retrospective study included patients attending the CReATe Fertility Centre between October 2018 and July 2021 who received intrauterine PRP infusion to prepare the endometrium for frozen embryo transfer. PRP was prepared from 21 cc of whole blood using the 2-step centrifugation method to yield 0.5–0.75 cc of concentrated platelets. Endometrial thickness was measured before infusion and within 72 h after infusion. All embryos transferred were tested for genetic abnormalities using next-generation sequencing.ResultsA total of 85 patients, 133 cycles, and 211 infusions were included. The majority of patients (56.5%) were diagnosed with RIF, some with TE (27.0%), and the remainder with both RIF and TE (16.5%). The majority of patients received one PRP infusion per cycle (55%). The endometrial thickness significantly increased across all diagnoses with a significant increase of 1.0 mm (0.5–1.7), which was also significantly greater than in previous cycles. The clinical pregnancy rate per embryo transfer after intrauterine PRP infusion was significantly greater compared to previous cycles (37% vs 20%, odds ratio 2.2) as was the live birth rate (19% vs 2%, odds ratio 11.6).ConclusionOur study suggests that PRP should be considered a noninvasive front-line therapy for improving endometrial thickness and implantation in patients with RIF, a TE, or both.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10815-022-02505-0.     

The role of low-molecular-weight heparin in recurrent implantation failure: a prospective, quasi-randomized, controlled study

Low-molecular-weight heparin did not provide any beneficial effect on pregnancy outcomes in patients with two or more implantation failures. Further trials are needed to confirm a trend in favor of low-molecular-weight heparin in the subgroup with women with three or more implantation failures.     

Association of progesterone receptor polymorphisms with recurrent implantation failure after in vitro fertilization and embryo transfer

Introduction Progesterone is the hormone of pregnancy and is required for its initiation. The actions of progesterone are mediated by the progesterone receptor. Polymorphic variants of human progesterone receptor genes have been implicated in implantation failure. Materials and methods We, therefore, investigated the prevalence of H770H(C/T genotype), V660L polymorphism and a 306 bp Alu insertion in exon 7 of the progesterone receptor among women with history of recurrent implantation failure to determine whether any of these polymorphisms may serve as a risk factor for implantation failure. DNA was extracted from the buccal swabs obtained from 66 women experiencing implantation failure and 75 fertile control women. PCR amplification of fragments was purified and the DNA sequenced to identify the polymorphism. The frequencies for the three variants were 27% for H770H, 21% for V660L and 0% for the 306 bp Alu insertion in exon 7 among women with implantation failure compared with control women of 25% for H770H and 24%for V660L and 0% for the 306 bp Alu insertion in exon 7. Discussion No significant differences in the overall allelic frequency of progesterone receptor variants was seen when women experiencing recurrent implantation failure were compared with control women. Conclusion We conclude that the H770H and V660L and PROGINS progesterone receptor polymorphisms are not markers that can identify women at risk for recurrent implantation after IVF/ET. Capsule H770H, V660L and PROGINS progesterone receptor polymorphisms were not found to be associated with recurrent implantation failure after IVF/ET.     

Endometrial extracellular vesicles of recurrent implantation failure patients inhibit the proliferation,migration, and invasion of HTR8/SVneo cells

Purpose

Endometrial extracellular vesicles are essential in regulating trophoblasts’ function. This study aims to investigate whether endometrial extracellular vesicles (EVs) from recurrent implantation failure (RIF) patients inhibit the proliferation, invasion, and migration of HTR8/SVneo cells.

Methods

Eighteen RIF patients and thirteen fertile women were recruited for endometria collection. Endometrial cells isolated from the endometria were cultured and modulated by hormones, and the conditioned medium was used for EV isolation. EVs secreted by the endometrial cells of RIF patients (RIF-EVs) or fertile women (FER-EVs) were determined by Western blotting, nanoparticle tracking analysis, and transmission electron microscopy. Fluorescence-labeled EVs were used to visualize internalization by HTR8/SVneo cells. RIF-EVs and FER-EVs were co-cultured with HTR8/SVneo cells. Cell Counting Kit-8, transwell invasion, and wound closure assays were performed to determine cellular proliferation, invasion, and migration, respectively, in different treatments.

Results

RIF-EVs and FER-EVs were bilayer membrane vesicles, ranging from 100 to 150 nm in size, that expressed the classic EV markers Alix and CD9. RIF-EVs and FER-EVs were internalized by HTR8/SVneo cells within 2 h. The proliferation rate in the FER-EV group was significantly higher than that in the RIF-EV group at 20 μg/mL. Moreover, the invasion and migration capacity of trophoblast cells were decreased in the RIF-EV group relative to the FER-EV group at 20 μg/mL.

Conclusion

Endometrial EVs from RIF patients inhibited the functions of trophoblasts by decreasing their proliferation, migration, and invasive capacity. Such dysregulations induced by RIF-EVs may provide novel insights for better understanding the pathogenesis of implantation failure.

     

复发性流产与反复种植失败相关危险因素比较

目的探讨复发性流产(RM)与反复种植失败(RIF)相关危险因素的联系与差异,为临床诊治提供依据。方法 2010年1月至2011年10月在南方医科大学南方医院生殖中心,选取RM患者68例及RIF患者22例进行男女双方染色体及女方的子宫解剖、内分泌、凝血、免疫共五方面筛查,比较两组基线资料及各方面异常率。结果 RM组免疫异常率及NK细胞异常率均显著高于RIF组(分别为94.1%vs.72.7%及84.4%vs.57.1%,χ2=5.687及χ2=5.278,P均<0.05);两组男方染色体异常率均高于女方,RM组双方染色体异常率分别为16.2%vs.5.9%(P>0.05),RIF组为36.4%vs.4.5%(χ2=3.387,P<0.05)。两组相关危险因素混合异常率(≥2项)分别为86.8%vs.77.3%(P>0.05),以高凝状态(86.8%vs.86.4%)及免疫异常(94.1%vs.72.7%)为主,其检测指标以狼疮抗凝物(LA)异常(58.2%vs.70.0%)及NK细胞异常(84.4%vs.57.1%)为主。结论 RM及RIF的相关危险因素均包括遗传、子宫解剖、内分泌、凝血、免疫五方面,且多为混合异常,均以凝血及免疫异常为主,而RM可能与外周血NK细胞增高更密切;此外,男方染色体异常比女方染色体异常与不良妊娠结局可能更相关。     

Effect of 1,25(OH)2 vitamin D3 on cytokine production by endometrial cells of women with repeated implantation failure

Repeated implantation failure (RIF) is a worldwide health problem that imposes a great deal of cost on patients and health care system. Vitamin D₃ has been proposed to have positive impact on the process of implantation. The present study was performed to compare the effect of 1,25-dihydroxy vitamin D₃ (1,25(OH)₂D₃) on cytokine production by endometrial cells of women with RIF and healthy fertile controls. Whole endometrial cells (WECs) and endometrial stromal cells (ESCs) from RIF and normal fertile women were treated with 1,25(OH)₂D₃. The levels of IL-10, TGF-β, IFNγ, Il-6, IL-8 and IL-17 in culture supernatants were assayed by ELISA. Also, ability of the cells from both groups to produce 1,25(OH)₂D₃ was evaluated and compared. 1,25(OH)₂D₃ down-regulated cytokine production in WECs from both groups except for IL-8 which was upraised. Similar trends were also observed in ESCs except up-regulation of TGF-β in RIF group. Endometrial cells of both groups had comparable capacity to produce 1,25(OH)₂D₃. Based on the minimal differential immunoregulatory effect of vitamin D₃ on endometrial cells from RIF and control women, it may be suggested that circulating levels of maternal vitamin D₃ be the subject of further investigation.     

Endometrial stromal cell proteome mapping in repeated implantation failure and recurrent pregnancy loss cases and fertile women

Research question

Are there proteomic differences between endometrial stromal cells of repeated implantation failure (RIF), recurrent pregnancy loss (RPL) and normal fertile women, and is there differential protein expression upon decidualization?

自体外周血单个核细胞(PBMCs)治疗改善反复种植失败患者妊娠结局的免疫学机制

辅助生殖技术飞速发展的同时,仍有部分患者中遭受反复胚胎种植失败(RIF)。RIF的治疗在不断更新和发展,RIF的免疫学病因和免疫治疗是否有效仍存在争议,相关的治疗是否有效尚未达成共识。目前有临床数据及动物实验显示,自体外周血单个核细胞(PBMC)治疗能改善该类患者的妊娠结局。然而,大多关于PBMC治疗均着重于临床现象,关于其具体的免疫学机制文章甚少。故本文对反复种植失败进行了概述并对PBMC治疗改善体外受精-胚胎移植(IVF-ET)RIF患者妊娠结局的免疫学机制进行了深入探讨与总结。     

Lack of correlation between hormonal blood levels and endometrial maturation in agonadal women with repeat implantation failure following embryo transfer from donated eggs

Five women with ovarian failure who repeatedly failed to conceive following embryo transfer from donated eggs underwent endometrial development investigation. One endometrial biopsy was obtained on cycle days 19, 21, and 23 during three consecutive artificially induced cycles. All five patients had only early secretory changes on days 19 and 21. Histological evaluation on cycle day 23 revealed various developmental stages: two women had in-phase endometrium, two patients had adequately developed stroma but significantly retarded glandular maturation, and one women showed no progress. The histological findings were conclusive for a significant maturation delay and an impaired endometrial receptivity. There was a lack of correlation between the peripheral hormonal blood levels and the endometrial maturation.     

Association between plasminogen activator inhibitor 1 gene mutation and different subgroups of recurrent miscarriage and implantation failure

Purpose

To compare plasminogen activator inhibitor type1 (PAI-1) mutation rates in different groups of patients with the record of recurrent miscarriage (RM) or implantation failure (IF) with special emphasis on the number of missed pregnancies and/or implantation failures (RM ≥ 2, IF ≥ 2, RM + IF ≥ 2, RM ≥ 3, IF ≥ 3 and RM + IF ≥ 3).

Method

Case-control study from PCR products and RFLP data of DNA from blood of patients who referred to the infertility clinic including 595 patients (421 RM ≥ 2, 119 IF ≥ 2 and 55 RM + IF ≥ 2) as the case groups and 100 healthy women as the control group.

Results

All six different subgroups of patients showed increased frequencies of the mutant allele (4G) in comparison to the control group (p < 0.001) suggesting a role for PAI-1 mutation in RM and IF.

Conclusions

The different patient subgroups suffer similar rates of risk in developing RM and IF when compared to controls.     

Evaluation of the endometrial receptivity assay and the preimplantation genetic test for aneuploidy in overcoming recurrent implantation failure

PurposeTo evaluate the clinical usefulness of the endometrial receptivity array (ERA) and the preimplantation genetic test for aneuploidy (PGT-A) in patients with severe and moderate recurrent implantation failure (RIF).DesignA retrospective multicenter cohort study was conducted in patients who failed to achieve implantation following transfer of 3 or more or 5 or more embryos in at least three single embryo transfers; patients were classified as moderate or severe RIF, respectively. Patients with previous RIF were compared based on the testing they received: PGT-A, ERA, or PGT-A+ERA versus a control group with no testing. Mean implantation rate and ongoing pregnancy rates per embryo transfer were considered primary outcomes. Multiple logistic regression analysis was performed and adjusted ORs were calculated to control possible bias.ResultsOf the 2110 patients belonging to the moderate RIF group, those who underwent transfer of euploid embryos after PGT-A had a higher implantation rate than those who did not. Additionally, the PGT-A group had a significantly higher rate of ongoing pregnancy. The same outcomes measured for the 488 patients in the severe RIF group did not reveal any statistically significant improvements. The use of the ERA test did not appear to significantly improve outcomes in either group.ConclusionsPGT-A may be beneficial for patients with moderate recurrent implantation failure but not for severe cases. At its current level of development, ERA does not appear to be clinically useful for patients with RIF.Electronic supplementary materialThe online version of this article (10.1007/s10815-020-01948-7) contains supplementary material, which is available to authorized users.     

The effect of preimplantation genetic screening on the probability of live birth in young women with recurrent implantation failure; a nonrandomized parallel group trial

Objective

The aim of this study was to evaluate the efficacy of preimplantation genetic screening (PGS) in women younger than 38 years and who had recurrent implantation failure (RIF).

Study design

A prospective nonrandomized parallel group study was performed in the assisted reproduction unit of a private tertiary care hospital. 140 infertile couples who had three or more previous failed cycles were included. Genetic counseling was given and couples who opted for another treatment cycle with PGS (n = 54) formed the PGS group whereas couples who declined PGS formed the control group (n = 86). In the PGS group, following FISH analysis for the detection of chromosomes 13, 16, 18, 21, 22, X and Y, only euploid embryos were transferred on day 5. In the control group embryo transfer was performed on day 3. Clinical pregnancy and live birth rates were compared. 95% confidence intervals for differences between the groups were calculated.

Results

Baseline and treatment cycle characteristics were similar in both groups. In the PGS group, a mean number of two embryos were transferred; there were 8 clinical pregnancies (14.8%). The implantation rate was 11.9%. There were no miscarriages and the live birth rate was 14.8%. In the control group, a mean number of 2.7 embryos were transferred resulting in 23 pregnancies (26.7%). The implantation rate was 18.4%. There were 2 miscarriages and the live birth rate was 24.4%. The differences among the groups were not statistically significant.

Conclusion

The results suggest that this particular group of young patients with RIF may not benefit from PGS. However, PGS is a multistep procedure that is highly human dependent, and results may vary across laboratories.     

Effect of empiric intravenous intralipid therapy on pregnancy outcome in women with unexplained recurrent implantation failure undergoing intracytoplasmic sperm injection-embryo transfer cycle: a randomized controlled trial

Abstract

To evaluate the effect of empiric intralipid infusion therapy on pregnancy outcomes for patients with unexplained recurrent implantation failure (RIF) undergoing intracytoplasmic sperm injection (ICSI). A total of 142 patients with a history of unexplained RIF (3 or more cycles) were included in this randomized controlled trial. Patients were randomized into two groups, study group (n?=?71) and control group (n?=?71). The study group received intralipid 20% infusion on the day of embryo transfer (ET) and a second dose on the day of pregnancy test. The clinical pregnancy rate in the study group was 36.6% (n?=?26) compared to 28.2% (n?=?20) in the control group (OR 1.47, CI 0.72–2.98, p?=?.282). The live birth rate in the study group was 18.3% (n?=?13) and 14.1% (n?=?10) in the control group (OR 1.37, CI 0.55–3.36, p=.49). No side effects of intralipid therapy were reported in the study period. There was improvement in the pregnancy rate among women with unexplained RIF who received empiric intralipid infusion therapy; however, this improvement did not reach statistical significance.     

Single and double endometrial scratching (ES) in infertile women with strict criteria of recurrent implantation failure (RIF)

Abstract

Controversies surrounding the effect of ES on pregnancy outcome in women with RIF are mostly due to the poorly defined target population. We evaluated the effect of ES on clinical outcomes in women with strict criteria of RIF before IVF/ICSI. We also examined the effect of ES on the expression of markers of endometrial receptivity. Women with failed implantation after transfer of seven or more top quality day 3 embryos or three blastocysts underwent the scratch procedure on exact days of the cycle prior to IVF/ICSI. Results were compared to no scratch control group. Using histopathology, immunohistochemistry, and scanning electron microscopy, we also examined the effect of injury on the endometrial receptivity in a separate series of observations with double ES. Cumulative pregnancy rate was significantly higher in the study group as compared to control (54.8% vs. 29.0%; p?<?.05). The effect of ES on the clinical outcome was seen during fresh ET, but not on the next FET cycles. ES improves impaired endometrial receptivity by partially normalizing the expression of estrogen and progesterone receptors (ERs, PRs) and pinopodes. We concluded that in a well-defined subpopulation of infertile women with RIF, ES significantly enhances pregnancy rates. ES has a specific impact on endometrial receptivity normalizing the expression of some markers.