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de Moura GA, Rocha YM, Moura FLD, Freitas JDO, Rodrigues JPV, Gonçalves VP, Nicolete R. Immune system cells modulation in patients with reproductive issues: A systematic review approach. JBRA Assist Reprod 2024; 28:78-89. [PMID: 37962966 PMCID: PMC10936913 DOI: 10.5935/1518-0557.20230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/21/2023] [Indexed: 11/16/2023] Open
Abstract
The aim of this study was to carry out a systematic literature review to investigate the main immune cells responsible for implantation failures. We selected papers from PubMed, Embase and Virtual Health Library databases. Eligible articles included publications between January 1, 2010 and April 24, 2022. Inclusion criteria were: observational and case-control studies; and the exclusion criteria were: review papers, letters to the editor, abstracts, animal studies and case reports. We extracted the following information: day of collection, number of patients, control group, age of patients, type of sample used, immune cells and cytokines. As main findings in our mapping, we found that in peripheral blood, CD3+, CD4+, CD8+, CD16+, CD56+, CD57+, CD69+, CD154+, CD158a+, NKp46 cells were increased and the CD4+, CD45+, Foxp3 and NKp46 markers were reduced. From the endometrial biopsies, there was an increase in CD3+, CD4+, CD5+, CD8+, CD16+, CD25+, CD45+, CD56+, CD57+, CD68+, CD127+ and a reduction in CD45+, CD56+, NKp46 and FoxP3 cells. Cytokines found increased in peripheral blood included IL-6, IL-10, IL-17, INF-γ, TGF-ß, TNF-α; while IL-4, IL-6, IL-10, IL-35, FoxP3, TGF-ß, SOCS3 were reduced. As for the biopsies, there was an increase in IL-2, IL-6, IL-17, IL-22, IL-23, INF-A1, INF-B1, INF-γ, TNF-R and a reduction in IL-6, IL-10, INF-γ, TGFß, TNF-α. We concluded that immune cells can be modulated during pregnancy failure, but further studies are needed to elucidate the modulating effect of the immune system on the endometrium of these patients.
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Affiliation(s)
- Gabriel Acácio de Moura
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | - Yasmim Mendes Rocha
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | | | | | - João Pedro Viana Rodrigues
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | - Vanessa Pinheiro Gonçalves
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
- North Northeast Biotechnology Network (RENORBIO), State University
of Ceará (UECE), Fortaleza, CE, Brazil
| | - Roberto Nicolete
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
- North Northeast Biotechnology Network (RENORBIO), State University
of Ceará (UECE), Fortaleza, CE, Brazil
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Khairy M, Harb H, Eapen A, Melo P, Kazem R, Rajkhowa M, Ndukuwe G, Coomarasamy A. The use of immunomodulation therapy in women with recurrent implantation failure undergoing assisted conception: A multicentre cohort study. Am J Reprod Immunol 2024; 91:e13819. [PMID: 38348954 DOI: 10.1111/aji.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/15/2024] Open
Abstract
PROBLEM Recurrent implantation failure (RIF) after multiple embryo transfers remains a vexing problem and immunomodulators have been used with conflicting results. This study aims to assess the effect of immunomodulation therapy on live birth rate (LBR) in women with RIF undergoing assisted reproduction treatment (ART). METHOD OF STUDY DESIGN This is a retrospective cohort study in multicentre network of private assisted conception units in the UK. The study included women who had at least two failed attempts of embryo transfers at CARE fertility network in the period from 1997 to 2018. Women in the treatment group had immunomodulator drugs in the form of corticosteroids, low molecular weight heparin (LMWH), and intravenous intralipid (IVIL) infusions, either separately or in combination, after immunological testing, in addition to standard ART whilst women in the control group had only ART without immunomodulators. The primary outcome was LBR per cycle. Secondary outcomes included the rates of clinical pregnancy (CPR), cumulative live birth (CLBR), and miscarriage. RESULTS A total of 27 163 ART cycles fulfilled the inclusion criteria, of which 5083 had immunomodulation treatment in addition to standard ART treatment, and 22 080 had standard ART treatment alone. Women in the treatment group were significantly older (mean age 38.5 vs. 37.1 years, p < .001), and had a higher number of previous failed ART cycles (mean 4.3 vs. 3.8, p < .01). There was a higher LBR in women who received immunomodulation therapy when compared with the control group (20.9% vs. 15.8%, odds ratio [OR] 1.4, 95% confidence interval [CI] 1.29-1.53, p < .001). Multivariate regression analysis showed that immunomodulation treatment was a significant independent predictor of live birth after adjusting for other confounders (adjusted OR [aOR] 1.33, 95% CI 1.15-1.54, p < .001). Survival analysis showed a higher CLBR in the treatment group (adjusted hazard ratio [aHR] 1.78, 95% CI 1.62-1.94, p < .001). CONCLUSION(S) This study provides evidence of a potential beneficial effect of immunomodulation therapy in women with RIF after immunological testing. There remains a need for high quality, adequately powered multicentre RCTs to robustly address the role of immunomodulation in women with RIF. There is also an urgent need for standardised screening tests for immune disorders that could preclude implantation.
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Affiliation(s)
| | - Hoda Harb
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Edgbaston, UK
| | - Abey Eapen
- Department of Obstetrics and Gynaecology, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Pedro Melo
- CARE Fertility Birmingham, Birmingham, Edgbaston, UK
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Edgbaston, UK
| | | | | | | | - Arri Coomarasamy
- CARE Fertility Birmingham, Birmingham, Edgbaston, UK
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Edgbaston, UK
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Mukherjee N, Sharma R, Modi D. Immune alterations in recurrent implantation failure. Am J Reprod Immunol 2023; 89:e13563. [PMID: 35587052 DOI: 10.1111/aji.13563] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/01/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
A failure to achieve pregnancy after three or more embryo transfer cycles with high-quality blastocysts is referred to as recurrent implantation failure (RIF). RIF can be due to altered uterine factors or male factors or embryo factors. Disrupted endometrial receptivity, altered expression of genes in several pathways, immunologic disturbances in the peripheral blood and/or the endometrium, and epigenetic alterations are associated with RIF. Amongst the immunologic disturbances, altered Th1/Th2 ratio, altered NK cell and macrophage numbers are observed in women with RIF. However, not all women with RIF have the same kind of immune dysfunction suggesting that RIF is a heterogeneous condition associated with varied immune responses and one size may not fit all. Thus, personalized therapies based on the immune status of the patient are being tested in women with RIF. In general, women with a high Th1/Th2 ratio are offered Tacrolimus, while intravenous IgG is recommended in women with high NK cell numbers/HLA mismatch. Women with hyperactivated immune status in the uterus are offered progesterone support, prednisolone, vitamin E, and intralipid treatment to suppress inflammation and oxidative stress, while endometrial scratching and intrauterine hCG administration are offered to women with hypo-active immune status. There is a need for standardized tests for evaluation of immune status in patients and sufficiently powered randomized controlled trials for personalized therapies to determine which of these will be beneficial in women with RIF. Till then, the ART community should limit the use of such add-on interventions in women with RIF.
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Affiliation(s)
- Nupur Mukherjee
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
| | - Richa Sharma
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
| | - Deepak Modi
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
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Genest G, Banjar S, Almasri W, Beauchamp C, Benoit J, Buckett W, Dzineku F, Gold P, Dahan MH, Jamal W, Jacques Kadoch I, Kadour-Peero E, Lapensée L, Miron P, Shaulov T, Sylvestre C, Tulandi T, Mazer BD, Laskin CA, Mahutte N. Immunomodulation for unexplained recurrent implantation failure: where are we now? Reproduction 2023; 165:R39-R60. [PMID: 36322478 DOI: 10.1530/rep-22-0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/02/2022] [Indexed: 11/05/2022]
Abstract
In brief Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies. Abstract Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.
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Affiliation(s)
- Geneviève Genest
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Shorooq Banjar
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Walaa Almasri
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Coralie Beauchamp
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Joanne Benoit
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - William Buckett
- McGill University Health Centre Reproductive Centre, Montreal, Quebec, Canada
| | | | - Phil Gold
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wael Jamal
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | | | - Einav Kadour-Peero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Louise Lapensée
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Pierre Miron
- Fertilys Reproductive Center, Laval, Quebec, Canada
| | - Talya Shaulov
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Sylvestre
- Division of Reproductive Endocrinology and Infertility, University of Montreal, Montreal, Quebec, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bruce D Mazer
- Department of Pediatrics, McGill University, Division of Allergy Immunology and Clinical Dermatology, Montreal Children's Hospital, McGill University, Montréal, Quebec, Canada
| | - Carl A Laskin
- Deptartments of Medicine and Obstetrics & Gynecology University of Toronto, Toronto, Ontario, Canada
| | - Neal Mahutte
- The Montreal Fertility Centre, Montreal, Quebec, Canada
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5
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Evidence for the effectiveness of immunologic therapies in women with subfertility and/or undergoing assisted reproduction. Fertil Steril 2022; 117:1144-1159. [PMID: 35618357 DOI: 10.1016/j.fertnstert.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/23/2023]
Abstract
Implantation is a critical step in the establishment of a successful pregnancy, depending on a complex immune-endocrine dialogue between the developing embryo and maternal endometrium. Research suggests that altered immunity in the maternal decidua results in implantation impairment and failure. Immunomodulatory drugs have, thus, been widely used in assisted conception to aid embryo implantation, despite an absence of consensus on their effectiveness and safety. We conducted a systematic review and meta-analysis of interventional studies investigating the use of immunomodulators in women undergoing assisted reproduction. Evidence was uncertain of an effect for most of the included interventions, owing to heterogeneous findings and a paucity of high-quality studies. For certain patient subgroups, however, the use of specific immunomodulatory therapies may offer some benefit. There is a need for further large randomized controlled trials to corroborate these findings.
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Kumar P, Marron K, Harrity C. Intralipid therapy and adverse reproductive outcome: is there any evidence? REPRODUCTION AND FERTILITY 2022; 2:173-186. [PMID: 35118388 PMCID: PMC8788620 DOI: 10.1530/raf-20-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022] Open
Abstract
Controversy exists regarding the benefits of intravenous intralipid therapy in patients with a poor reproductive history. It is frequently reported that there is no evidence to support the effectiveness, utility or safety for this treatment. While individual studies may be perceived as weak, a systematic review and meta-analysis were performed to determine if there is any advantage to patients. PubMed, Embase and Scopus searches were performed with the target populations being either recurrent pregnancy loss (RPL), or recurrent implantation failure (RIF) undergoing assisted reproductive technology (ART) and receiving intralipid infusions. These cohorts were compared with either placebo, no intervention or alternative treatments. The most relevant outcome measures were considered to be clinical pregnancy rate (CPR), live birth rate (LBR), implantation rate (IR) and miscarriage rate (MR). Twelve studies encompassing 2676 participants met the criteria for selection and were included and reviewed. Treatment of the target population with intralipid led to an improvement in IR (Odds Ratio (OR): 2.97, 2.05–4.29), pregnancy rate (OR: 1.64, 1.31–2.04), and LBR (OR: 2.36, 1.75–3.17), with a reduction in MR (OR: 0.2, 0.14–0.30). Although intravenous intralipid is not recommended as a routine treatment for recurrent miscarriage or implantation failure, there is enough data to suggest consideration in selected patients where routine testing is unremarkable, standard treatments have failed and immunological risk factors are present. The presence of abnormal uterine natural killer (uNK) cells needs more study as a target marker to determine those who could benefit.
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Affiliation(s)
- Parijot Kumar
- Beaumont Hospital, Dublin, Ireland.,RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kevin Marron
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Conor Harrity
- Beaumont Hospital, Dublin, Ireland.,RCSI University of Medicine and Health Sciences, Dublin, Ireland.,ReproMed, Dublin, Ireland
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Turocy J, Williams Z. Novel therapeutic options for treatment of recurrent implantation failure. Fertil Steril 2021; 116:1449-1454. [PMID: 34836580 DOI: 10.1016/j.fertnstert.2021.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
Despite the challenges in studying recurrent implantation failure, progress is currently being made in therapeutic options to help those who suffer from recurrent implantation failure. Three of the most promising therapeutic options for recurrent implantation failure include immune therapies such as peripheral blood mononuclear cells, platelet rich plasma and subcutaneous granulocyte-colony stimulating factor.
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Affiliation(s)
- Jenna Turocy
- Columbia University Fertility Center, New York, New York
| | - Zev Williams
- Columbia University Fertility Center, New York, New York.
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8
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Wang C, Guan D, Li R, Bing Z, Yang Y, Yang K. Comparative efficacies of different immunotherapy regimens in recurrent implantation failure: A systematic review and network meta-analysis. J Reprod Immunol 2021; 148:103429. [PMID: 34638024 DOI: 10.1016/j.jri.2021.103429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
For patients with recurrent implantation failure (RIF), immune system imbalances have become the focus of research. The effects of different classes of immunotherapies on improving pregnancy outcomes have not been fully established. This network meta-analysis was performed to assess the impact of popular immunotherapies in women with RIF. We systematically searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of Science databases as well as clinical trial registration websites. Randomized controlled trials comparing immunotherapeutic outcomes were included. We performed the random-effects network meta-analysis to compare efficacy measures. A total of 21 trials involving 2277 participants and 8 immunotherapies were eligible for this study. Patients that had been administered with PBMCs, G-CSF, PRP, and sirolimus exhibited higher CPR than those administered with the placebo (2.63, 1.71-4.06; 2.03, 1.35-3.05; 1.98, 1.02-3.84; 2.55, 1.36-4.79; and 3.95, 1.33-11.72, respectively). For IR, only PBMCs and G-CSF were significantly more effective than the placebo (2.92, 1.39-6.12; 2.66, 1.16-6.06, respectively). In terms of LBR, PBMCs (2.96, 1.67-5.27) and sirolimus (3.55, 1.18-10.64) were effective. However, r-hLIF (0.25, 0.10-0.62) had a reduced risk of LBR. No therapeutic regimen was found to have significantly decreased MR, but PBMCs exhibited the lowest rank among all interventions (0.28, 0.06-1.44). To improve clinical pregnancy while reducing miscarriage outcomes, PBMCs might be a beneficent therapeutic option for RIF in the future.
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Affiliation(s)
- Caiyun Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; Department of Obstetrics and Gynecology, The First Hospital of Lanzhou University, Lanzhou, China; Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Defeng Guan
- Reproductive Medicine Center of the First Hospital of Lanzhou University, Lanzhou, China
| | - Rui Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China; Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhitong Bing
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Yongxiu Yang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; Department of Obstetrics and Gynecology, The First Hospital of Lanzhou University, Lanzhou, China.
| | - Kehu Yang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China; Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China.
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9
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Han EJ, Lee HN, Kim MK, Lyu SW, Lee WS. Efficacy of intralipid administration to improve in vitro fertilization outcomes: A systematic review and meta-analysis. Clin Exp Reprod Med 2021; 48:203-210. [PMID: 34488285 PMCID: PMC8421665 DOI: 10.5653/cerm.2020.04266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/06/2021] [Indexed: 11/06/2022] Open
Abstract
We performed a systematic review and meta-analysis to evaluate whether intralipid administration improved the outcomes of in vitro fertilization. Online databases (PubMed, Cochrane Library, Medline, and Embase) were searched until March 2020. Only randomized controlled trials (RCTs) that assessed the role of intralipid administration during in vitro fertilization were considered. We analyzed the rates of clinical pregnancy and live birth as primary outcomes. Secondary outcomes included the rates of chemical pregnancy, ongoing pregnancy, and missed abortion. We reviewed and assessed the eligibility of 180 studies. Five RCTs including 840 patients (3 RCTs: women with repeated implantation failure, 1 RCT: women with recurrent spontaneous abortion, 1 RCT: women who had experienced implantation failure more than once) met the selection criteria. When compared with the control group, intralipid administration significantly improved the clinical pregnancy rate (risk ratio [RR], 1.48; 95% confidence interval [CI], 1.23-1.79), ongoing pregnancy rate (RR, 1.82; 95% CI, 1.31-2.53), and live birth rate (RR, 1.85; 95% CI, 1.44-2.38). However, intralipid administration had no beneficial effect on the miscarriage rate (RR, 0.75; 95% CI, 0.48-1.17). A funnel plot analysis revealed no publication bias. Our findings suggest that intralipid administration may benefit women undergoing in vitro fertilization, especially those who have experienced repeated implantation failure or recurrent spontaneous abortion. However, larger, well-designed studies are needed to confirm these findings.
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Affiliation(s)
- E Jung Han
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Hye Nam Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Min Kyoung Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Sang Woo Lyu
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Woo Sik Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
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10
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Foyle KL, Sharkey DJ, Moldenhauer LM, Green ES, Wilson JJ, Roccisano CJ, Hull ML, Tremellen KP, Robertson SA. Effect of Intralipid infusion on peripheral blood T cells and plasma cytokines in women undergoing assisted reproduction treatment. Clin Transl Immunology 2021; 10:e1328. [PMID: 34408876 PMCID: PMC8358997 DOI: 10.1002/cti2.1328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives Intravenous infusion of Intralipid is an adjunct therapy in assisted reproduction treatment (ART) when immune‐associated infertility is suspected. Here, we evaluated the effect of Intralipid infusion on regulatory T cells (Treg cells), effector T cells and plasma cytokines in peripheral blood of women undertaking IVF. Methods This prospective, observational pilot study assessed Intralipid infusion in 14 women exhibiting recurrent implantation failure, a clinical sign of immune‐associated infertility. Peripheral blood was collected immediately prior to and 7 days after intravenous administration of Intralipid. Plasma cytokines were measured by Luminex, and T‐cell subsets were analysed by flow cytometry. Results A small increase in conventional CD8+ T cells occurred after Intralipid infusion, but no change was seen in CD4+ Treg cells, or naïve, memory or effector memory T cells. Proliferation marker Ki67, transcription factors Tbet and RORγt, and markers of suppressive capacity CTLA4 and HLA‐DR were unchanged. Dimensionality‐reduction analysis using the tSNE algorithm confirmed no phenotype shift within Treg cells or other T cells. Intralipid infusion increased plasma CCL2, CCL3, CXCL8, GM‐CSF, G‐CSF, IL‐6, IL‐21, TNF and VEGF. Conclusion Intralipid infusion elicited elevated pro‐inflammatory cytokines, and a minor increase in CD8+ T cells, but no change in pro‐tolerogenic Treg cells. Notwithstanding the limitation of no placebo control, the results do not support Intralipid as a candidate intervention to attenuate the Treg cell response in women undergoing ART. Future placebo‐controlled studies are needed to confirm the potential efficacy and clinical significance of Intralipid in attenuating cytokine induction and circulating CD8+ T cells.
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Affiliation(s)
- Kerrie L Foyle
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - David J Sharkey
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Lachlan M Moldenhauer
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Ella S Green
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Jasmine J Wilson
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Cassandra J Roccisano
- School of Pharmacy and Medical Sciences University of South Australia Adelaide SA Australia
| | - M Louise Hull
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Kelton P Tremellen
- School of Medicine Flinders University Adelaide SA Australia.,Repromed Pty Ltd Dulwich SA Australia
| | - Sarah A Robertson
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
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11
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Parhizkar F, Motavalli-Khiavi R, Aghebati-Maleki L, Parhizkar Z, Pourakbari R, Kafil HS, Danaii S, Yousefi M. The Impact of New Immunological Therapeutic Strategies on Recurrent Miscarriage and Recurrent Implantation Failure. Immunol Lett 2021; 236:20-30. [PMID: 34090942 DOI: 10.1016/j.imlet.2021.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/12/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022]
Abstract
Maternal-fetal immune dysregulation is one of the risk factors that increases the probability of embryo rejection and reproductive failure. The stimulation of immunological tolerance and suppression of immunological rejection are prerequisites for protecting embryos and preventing immunological attacks. Hence, it appears that immunomodulatory and immunosuppressive therapies can manage reproductive failures by controlling immune cells. The current medical literature has shown that immunotherapy approaches and cell therapy have promising results in improving pregnancy outcomes and live birth rates. These outcomes are obtained by regulating maternal immune responses, and exerting positive effects on human reproductive processes.
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Affiliation(s)
- Forough Parhizkar
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Roza Motavalli-Khiavi
- Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Zahra Parhizkar
- Student Research Committee, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ramin Pourakbari
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Shahla Danaii
- Gynecology Department, Eastern Azerbaijan ACECR ART Centre, Eastern Azerbaijan branch of ACECR, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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12
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"Add-Ons" for Assisted Reproductive Technology: Do Patients Get Honest Information from Fertility Clinics' Websites? Reprod Sci 2021; 28:3466-3472. [PMID: 33939166 DOI: 10.1007/s43032-021-00601-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
"Add-on" procedures are actively promoted on some fertility clinic websites as proven means to improve IVF success rates, especially for couples with repeated implantation/IVF failures. However, the actual contribution of these interventions to live birth rates remains inconclusive. At present, little is known about the type and quality of the information provided on the IVF clinics' websites regarding the merits of "add-ons." A systematic evaluation of the quality of information on "add-on" procedures in fertility clinic websites was performed using 10-criteria structured questionnaire. We included English language websites that presented in the Google.com search engine after typing the following key-words:"endometrial scratching"(ES), "intralipid infusions"(ILI), "assisted hatching"(AHA), "PGT-A," or "PGS". In total, 254 websites were evaluated. In most cases, an accurate description of the "add-on" procedures was provided (78.8%). However, only a minority (12%) reported their undetermined effectiveness. The use of PGT-A was more often encouraged (52.8%) than ES (23.6%) and AHA (16%). The cost was infrequently presented (6.9%). Scientific references were only rarely provided for ILI, versus 12.7% for ES, 4.0% for AHA, and 5.6% for PGT-A. The information entry date was often missing. None of the websites reported the clinic's pregnancy-rate following the "add-on" procedures. Information on "add-ons" available to patients from IVF clinic websites is often inaccurate. This could perpetuate false myths among infertile patients about these procedures and raises concern regarding possible commercial bias. It is imperative that IVF clinic websites will better communicate the associated risks and uncertainties of "add-ons" to prospective patients.
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13
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Rimmer MP, Black N, Keay S, Quenby S, Al Wattar BH. Intralipid infusion at time of embryo transfer in women with history of recurrent implantation failure: A systematic review and meta-analysis. J Obstet Gynaecol Res 2021; 47:2149-2156. [PMID: 33754451 DOI: 10.1111/jog.14763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 01/15/2023]
Abstract
AIM Recurrent implantation failure (RIF) affects 10% of couples undergoing assisted conception, often due to poor endometrial receptivity. We conducted a systematic review and meta-analysis to evaluate the effectiveness of Intra-venous intralipid (IVI) in improving pregnancy rates in women with history of RIF using. METHODS We searched MEDLINE, EMBASE, and CENTRAL for any randomized trials evaluating the use of IVI at the time of embryo transfer in women undergoing assisted conception until September 2020. We extracted data in duplicate and assessed risk of bias using the Cochrane Risk of Bias tools. We meta-analyzed data using a random effect model. RESULTS We included five randomized trials reporting on 843 women with an overall moderate risk of bias. All trials used 20% IVI solution at the time of embryo transfer compared to normal saline infusion or no intervention (routine care). The IVI group had a higher chance of clinical pregnancy (172 vs 119, risk ratio [RR] 1.55, 95% confidence interval [CI] 1.16-2.07, I2 44.2%) and live birth (132 vs 73, RR 1.83, 95% CI 1.42-2.35, I2 0%) post treatment compared to no intervention. Our findings are limited by the small sample size and the variations in treatment protocols and population characteristics. CONCLUSION There is limited evidence to support the use of IVI at the time of embryo transfer in women with the history of RIF. More research is needed before adopting it in clinical practice.
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Affiliation(s)
- Michael P Rimmer
- MRC Centre for Reproductive Health, Queens Medical Research Institute, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, UK
| | - Naomi Black
- Warwick Medical School, Warwick University, Coventry, UK.,University Hospital Coventry and Warwickshire, Coventry, UK
| | - Stephen Keay
- University Hospital Coventry and Warwickshire, Coventry, UK
| | - Siobhan Quenby
- Warwick Medical School, Warwick University, Coventry, UK.,University Hospital Coventry and Warwickshire, Coventry, UK
| | - Bassel H Al Wattar
- Warwick Medical School, Warwick University, Coventry, UK.,University Hospital Coventry and Warwickshire, Coventry, UK
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14
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Efficacy of therapies and interventions for repeated embryo implantation failure: a systematic review and meta-analysis. Sci Rep 2021; 11:1747. [PMID: 33462292 PMCID: PMC7814130 DOI: 10.1038/s41598-021-81439-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/21/2020] [Indexed: 01/29/2023] Open
Abstract
The aim of the present systematic review and meta-analysis was to assess the effect of the different therapeutic options for repeated embryo implantation failure (RIF) on a subsequent IVF cycle outcome. Twenty-two RCTs and nineteen observational studies were included. Pooling of results showed a beneficial effect of intrauterine PBMC infusion on both CPR (RR 2.18; 95% CI 1.58-3.00; p < 0.00001; OR 2.03; 95% CI 1.22-3.36; p = 0.006) and LBR (RR 2.41; 95% CI 1.40-4.16; p = 0.002; OR 3.73; 95% CI 1.13-12.29; p = 0.03), of subcutaneous G-CSF administration on CPR (RR 2.29; 95% CI 1.58-3.31; p < 0.0001) and of intrauterine PRP infusion on CPR (RR 2.45; 95% CI 1.55-3.86; p = 0.0001). Observational studies also demonstrated a positive effect of IVIG and intrauterine hCG infusion on both CPR and LBR and of atosiban on CPR. Studies investigating intrauterine G-CSF infusion, LMWH, intravenous intralipid, hysteroscopy, blastocyst-stage ET, ZIFT, PGT-A and AH failed to observe an impact on IVF outcome. The quality of the evidence that emerged from RCTs focused on intrauterine PBMC infusion and subcutaneous G-CSF administration was moderate. For all other therapies/interventions it varied from low to very low. In conclusion, intrauterine PBMC infusion and subcutaneous G-CSF administration are the most promising therapeutic options for RIF. However, further well conducted RCTs are necessary before their introduction into clinical practice.
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15
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On use of animal models. Emerg Top Life Sci 2020; 4:207-227. [PMID: 32691841 DOI: 10.1042/etls20200042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/16/2022]
Abstract
Human pregnancy, critical for our species survival, is inefficient and prone to complications such as infertility, spontaneous miscarriages and preeclampsia (PE). Immunological factors may be important as the embryo is 50% paternal and foreign to the mother. Mouse pregnancy models, and in particular the murine CBA/J x DBA/2 mating combination, has been widely used to investigate mechanisms causing and preventing partner-specific recurrent miscarriages (RM) and PE. Occult losses can represent T cell-mediated rejection, and antigen-specific regulatory T cells (Tregs) with classical αβ T cell receptors (TcR) activated by semen antigens at the time of mating are protective. If there is no occult loss, an inadequate Treg response can also predispose to RM. In RM, proinflammatory cytokines from natural killer (NK)-type cells and macrophages of the innate immune system are responsible and cells with γδ TcR protect via release of TGF-β-type molecules. Immunization of abortion-prone female CBA/J mice or administration of cell-associated or soluble CD200, an immune check point inhibitor, can prevent abortions by augmenting uterine decidual suppressor cell activity. Human studies suggest that is also true in couples with RM. Environmental activators of the innate immune system, such as bacterial LPS and stress, can cause abortions as well as occult losses. The endogenous level of Tregs and activation of Tregs specific for the male H-Y antigen may determine success rates and alter the male:female birth ratio. Intralipid alters LPS clearance, prevents abortions in the CBAxDBA/2 model, and is effective in increasing live birth rates in couples undergoing IVF treatment.
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16
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Baron C, Haouzi D, Gala A, Ferrieres-Hoa A, Vintejoux E, Brouillet S, Hamamah S. [Endometrial receptivity in assisted reproductive techniques: An aspect to investigate in embryo implantation failure]. ACTA ACUST UNITED AC 2020; 49:128-136. [PMID: 32721539 DOI: 10.1016/j.gofs.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 10/23/2022]
Abstract
Infertility affects between 8 and 12% of reproductive-age couples worldwide. Despite improvements in assisted reproductive techniques (ART), live birth rates are still limited. In clinical practice, imaging and microscopy are currently widely used, but their diagnostic effectiveness remains limited. In research, the emergence of innovative techniques named OMICS would improve the identification of the implantation window, while progressing in the understanding of the pathophysiological mechanisms involved in embryo implantation failures. To date, transcriptomic analysis seems to be the most promising approach in clinical research. The objective of this review is to present the results obtained with the different approaches available in clinical practice and in research to assess endometrial receptivity in patients undergoing ART.
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Affiliation(s)
- C Baron
- Inserm U1203, développement embryonnaire précoce humain et pluripotence, université Montpellier, Montpellier, France
| | - D Haouzi
- Inserm U1203, développement embryonnaire précoce humain et pluripotence, université Montpellier, Montpellier, France
| | - A Gala
- Département de biologie de la reproduction, biologie de la reproduction et diagnostic pre-implantatoire, université Montpellier, CHU Montpellier, Montpellier, France
| | - A Ferrieres-Hoa
- Département de biologie de la reproduction, biologie de la reproduction et diagnostic pre-implantatoire, université Montpellier, CHU Montpellier, Montpellier, France
| | - E Vintejoux
- Département de médecine de la reproduction, CHU de Montpellier, 34000 Montpellier, France
| | - S Brouillet
- Inserm U1203, développement embryonnaire précoce humain et pluripotence, université Montpellier, Montpellier, France; Département de biologie de la reproduction, biologie de la reproduction et diagnostic pre-implantatoire, université Montpellier, CHU Montpellier, Montpellier, France; Inserm 1036, laboratoire biologie du cancer et de l'infection (BCI), Commissariat à l'énergie atomique et aux énergies alternatives (CEA), institut de biosciences et biotechnologies de Grenoble (BIG), université Grenoble-Alpes, 38000 Grenoble, France; Centre clinique et biologique d'assistance médicale à la procréation - centre d'étude et de conservation des œufs et du sperme humains (CECOS), hôpital Couple-Enfant, centre hospitalier universitaire de Grenoble, La Tronche, France.
| | - S Hamamah
- Inserm U1203, développement embryonnaire précoce humain et pluripotence, université Montpellier, Montpellier, France; Département de biologie de la reproduction, biologie de la reproduction et diagnostic pre-implantatoire, université Montpellier, CHU Montpellier, Montpellier, France.
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17
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Coulam CB. Intralipid treatment for women with reproductive failures. Am J Reprod Immunol 2020; 85:e13290. [DOI: 10.1111/aji.13290] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Carolyn B. Coulam
- Clinical Immunology Laboratory Rosalind Franklin University of Medicine and Science North Chicago IL USA
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18
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Zhou P, Wu H, Lin X, Wang S, Zhang S. The effect of intralipid on pregnancy outcomes in women with previous implantation failure in in vitro fertilization/intracytoplasmic sperm injection cycles: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:187-192. [PMID: 32622103 DOI: 10.1016/j.ejogrb.2020.06.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022]
Abstract
Several recent studies have investigated the relationship between intravenous intralipid and in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes in women with previous implantation failure. We conducted a systematic review and meta-analysis to evaluate the effects of intravenous intralipid on pregnancy outcomes in women with previous implantation failure. Ovid MEDLINE, the Cochrane Library, Embase and ClinicalTrials.gov were searched up to August 5th, 2019. Randomized controlled trials comparing intravenous intralipid with placebo or no treatment during IVF/ICSI cycles in women with at least one implantation failure were included. Results were presented as risk ratio (RR) with 95 % confidence intervals (CIs). Four studies with 544 participants were included. Live birth rate was statistically higher among the groups of women who received intravenous intralipid (RR 1.98, 95 % CI 1.39-2.80, quality of evidence: low). Intralipid infusion could significantly improve clinical pregnancy rate (RR 1.74, 95 % CI 1.27-2.40, quality of evidence: low). When excluding two studies only published as conference abstracts, there were no significant differences in terms of live birth (RR 1.78, 95 % CI 0.95-3.34, heterogeneity: I² = 25.5 %, quality of evidence: low, Fig. 4A) and clinical pregnancy (RR 1.66, 95 % CI 0.90-3.08, heterogeneity: I² = 47.7 %, quality of evidence: low, Fig. 4B). Adverse events were reported to be rare, but three congenital anomalies were observed in women receiving intravenous intralipid. Administering intravenous intralipid during IVF/ICSI cycles may improve live birth and clinical pregnancy in women with previous implantation failure, such benefit is not significant excluding studies with high risk of bias in the analysis, more studies are needed to evaluate its efficacy and safety especially congenital malformations.
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Affiliation(s)
- Ping Zhou
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
| | - Hanglin Wu
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, No. 369 Kun Peng Road, Hangzhou 310008, Zhejiang, China
| | - Xiaona Lin
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
| | - Shasha Wang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China.
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19
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Cavalcante MB, Cavalcante CTDMB, Sarno M, Barini R. Intrauterine perfusion immunotherapies in recurrent implantation failures: Systematic review. Am J Reprod Immunol 2020; 83:e13242. [PMID: 32248580 DOI: 10.1111/aji.13242] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 02/06/2023] Open
Abstract
Studies have investigated the gestational outcomes of new immunological therapies in the treatment of patients with recurrent implantation failure (RIF) in assisted reproductive technology (ART). The objective of this article is to assess the current state of evidence available in the literature on intrauterine perfusion immunotherapies in women undergoing ART treatments. By considering the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), the authors performed systematic review by searching the databases of PubMed/MEDLINE and Scopus using the following key words: "recurrent implantation failure," "intrauterine infusion," "Platelet-Rich Plasma (PRP)," "Peripheral Blood Mononuclear Cells (PBMC)," "Granulocyte Colony-Stimulating Factor (G-CSF)," and "Human Chorionic Gonadotropin (hCG)." The authors analyzed the indications and the impact of new immunological therapies with intrauterine infusions on the pregnancy outcomes of patients undergoing ART. PRP, PBMC, G-CSF, and hCG were the four most used immunological therapies with intrauterine infusion. These new therapies appear to improve the results of ART treatments in cases of RIF. However, the small number of studies does not allow definitive conclusions about the effectiveness of these therapies.
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Affiliation(s)
- Marcelo Borges Cavalcante
- Department of Obstetrics and Gynecology, Fortaleza University (UNIFOR), Fortaleza-CE, Brazil.,CONCEPTUS - Reproductive Medicine, Fortaleza-CE, Brazil
| | | | - Manoel Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, Brazil.,Harris Birthright Research Center for Fetal Medicine, King's College Hospital and Department of Fetal Medicine, University College London, London, UK
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP), Campinas, Brazil
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