Granulocyte colony-stimulating factor for intracytoplasmic sperm injection patients with repeated implantation failure: which route is best?†

Subcutaneous injection granulocyte colony-stimulating factor (G-CSF) is superior to intrauterine infusion on patients with recurrent implantation failure: A systematic review and network meta-analysis

Although both subcutaneous injection and intrauterine infusion of granulocyte colony-stimulating factor (G-CSF) have been reported to improve pregnancy outcomes in patients with recurrent implantation failure (RIF), how to administer it is still no consensus. The study aimed to investigate which administration route is optimal. We searched PubMed, Embase, the Cochrane Library (CENTRAL), Web of Science, and China National Knowledge Internet (CNKI) from inception to April 10, 2023, with language in both English and Chinese. The randomized controlled trials (RCTs) compared the effectiveness of G-CSF to treat patients with RIF were included in this network meta-analysis (NMA). The odds ratio (OR) and 95% confidence interval (CI) in pregnancy outcomes (implantation rate, IR; clinical pregnancy rate, CPR; live birth rate, LBR; miscarriage rate, MR; ectopic pregnancy rate, EPR) were summarized by NMA with a random-effects model. A total of 1360 RIF patients from 14 RCTs were included in this NMA, with no publication bias and small sample effects. No direct evidence compared the effectiveness of different administration routes of G-CSF on IR, LBR and MR. Both subcutaneous injection and intrauterine infusion of G-CSF increased the IR (OR = 2.81, 95% CI: 1.10-7.24; OR = 2.15, 95% CI: 1.50-3.07, respectively) and CPR (OR = 2.79, 95% CI: 1.86-4.17; OR = 1.74, 95% CI: 1.30-2.33, respectively) in patients with RIF. According to SUCRA, subcutaneous injection is more likely to be the optimal medication administration route. However, more high-quality studies were also needed to support these, especially IR and LBR.

Efficacy and safety of recombinant human granulocyte colony-stimulating factor in patients with poor ovarian response: protocol for a multicentre, randomised, controlled trial

INTRODUCTION

Approximately 17.5% of couples of reproductive age have experienced infertility. Women with a poor ovarian response (POR) must undergo in vitro fertilisation (IVF) and embryo transfer to achieve pregnancy. However, studies have reported a poor response to gonadotropin stimulation in women undergoing IVF-ET. Results from animal experiments suggest that granulocyte colony-stimulating factor (G-CSF) has a curative effect by protecting ovarian function, reducing follicle loss and delaying premature ovarian failure in rats caused by chemotherapy. Clinical studies on the therapeutic effect of G-CSF are deficient; therefore, this study will investigate its ability to improve ovum quality and maturity among women with POR undergoing IVF/intracytoplasmic sperm injection (ICSI).

METHODS AND ANALYSIS

This clinical, multicentre, triple-blind, placebo-controlled trial will employ balanced randomisation (1:1). The planned sample size is 312 participants (156 subjects in each group). A total of 312 patients with infertility undergoing IVF/ICSI will be recruited from four public hospitals in China. The participants will be randomly divided into an experimental group (G-CSF) and a placebo group (control). All patients will be treated by using the progestin-primed ovarian stimulation superovulation protocol. The primary outcome will be D3 embryo quality. The number of ova obtained, MII ova and transferable embryos will be inclusive in the secondary outcome.

ETHICS AND DISSEMINATION

To our knowledge, this is the first clinical trial to investigate the effect of G-CSF treatment timing and stimulation protocol in patients with POR in China. This study will provide new information about G-CSF efficacy among patients with POR undergoing IVF/ICSI and can help improve ovum quality and maturity. Clinical trials on this subject are deficient in China; therefore, a well-designed randomised trial is needed to determine the ability of G-CSF to improve ovum quality and maturity to facilitate conception among women with POR treated with IVF/ICSI.

TRIAL REGISTRATION NUMBER

ChiCTR2200062412.

Granulocyte colony-stimulating factor in assisted reproductive technology treatment does not increase the risk of adverse perinatal outcomes in twin pregnancies

The aim of the study is to compare the perinatal outcomes of twin pregnancies resulting from assisted reproductive technology (ART) treatment in which granulocyte colony-stimulating factor (G-CSF) was used with those in which it was not. In this retrospective study, the clinical data of 122 dichorionic diamniotic twin pregnancies were reviewed. Pregnancies were divided into two groups, G-CSF-treated and non-G-CSF treated. Maternal age, gestational week at birth, oligohydramnios, gestational hypertension, pre-eclampsia, preterm birth, first-trimester bleeding, gestational diabetes, rupture of membrane, foetal congenital anomalies, admission to the neonatal intensive care unit, birth weight (BW), small for gestational age, BW discordance, Apgar score and placental weight were compared between the groups.IMPACT STATEMENTWhat is already known on this subject? Granulocyte colony-stimulating factor (G-CSF) administrations increase pregnancy outcomes and do not have a negative effect on perinatal outcomes in singleton pregnancies.What the results of this study add? This study showed that the perinatal outcome of dichorionic diamniotic twin pregnancies conceived after assisted reproductive technology (ART) treatment was similar in the GSF administrated and non-GSF administrated groups.What the implications are of these findings for clinical practice and/or further research? Using G-CSF to increase the success of ART does not seem to have an adverse outcome in the dichorionic diamniotic twin pregnancies.

Recombinant human granulocyte colony stimulating factor (rhG-CSF) participates in the progression of implantation via the hsa_circ_0001550-miRNA-mRNA interaction network

Inadequate endometrial receptivity is a key factor affecting the successful implantation of embryos. Recombinant human granulocyte colony stimulating factor (rhG-CSF) can increase endometrial thickness and improve the outcomes of assisted reproductive technologies (ARTs). In this preliminary study, the function and possible molecular mechanisms of recombinant human granulocyte colony stimulating factor (rhG-CSF) which affects endometrial receptivity and implantation in human Embryonic Stem Cells (hESCs) were investigated. The cell viability of endometrial stromal cells treated with rhG-CSF 0.5 ng/ml for 24 h was significantly increased. Moreover, the expression of hsa_circ_0001550 was downregulated in endometrial stromal cells treated with rhG-CSF. Furthermore, the hsa_circ_0001550-miRNA-mRNA network was constructed and the downstream target genes (including 4 miRNAs and 117 mRNAs) of hsa_circ_0001550 were mainly involved in the cAMP and calcium signalling pathways, which play important roles in regulating endometrial receptivity and embryo implantation. We conclude that rhG-CSF participates in the regulation of embryo implantation by regulating the hsa_circ_0001550-miRNA-mRNA interaction network.

Treatment options for endometrial hypoproliferation

PURPOSE OF REVIEW

Endometrial hypoproliferation refers to the failure of the endometrium to reach optimal thickness during fresh or frozen embryo transfer cycles in women undergoing infertility treatment with in-vitro fertilization (IVF). This review discusses the treatment options for endometrial hypoproliferation.

RECENT FINDINGS

Apart from factors related to the embryo quality, ultrasonographic findings associated with the endometrium, such as endometrial thickness, endometrial pattern and subendometrial blood flow, are considered key factors associated with the outcome of assisted reproductive treatment. To date, a consensus has not been reached regarding the definition of thin endometrium, while thresholds of 6, 7 or 8 mm have been used in the literature. Strategies to increase endometrial thickness can be reviewed in three groups: endocrine approaches, vitamins & supplements, and new experimental therapeutic interventions. Some of the recently introduced experimental therapeutic interventions such as platelet-rich plasma injection, stem cell treatment and tissue bioengineering are exciting potential therapies that need to be further studied.

SUMMARY

Despite a large number of publications on the topic, diagnosing and treating endometrial hypoproliferation remains a challenge. Well designed studies are needed to establish a widely accepted endometrial thickness cut-off value below which endometrial hypoproliferation is diagnosed and to generate meaningful data that would allow an evidence-based discussion of available therapeutic options with patients.

Efficacy of granulocyte colony-stimulating factor for infertility undergoing IVF: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the effectiveness of granulocyte colony-stimulating factor (G-CSF) for infertility and recurrent spontaneous abortion.

METHODS

Existing research was searched in PubMed, Embase and Cochrane Library till Dec 2021. Randomized control trials (RCTs) that compared G-CSF administration with the control group in infertility women undergoing IVF were included. The primary outcomes included clinical pregnancy rate; the secondary outcomes included live birth rate, abortion ratebiochemical pregnancy rate, embryo implantation rate, as well as endometrial thickness.

RESULT(S)

20 RCTs were included in this study. G-CSF increased the clinical pregnancy rate (RR = 1.85; 95% CI: 1.07, 3.18) and the endometrial thickness (MD = 2.25; 95% CI: 1.58,2.92;) in patients with thin endometrium undergoing IVF. G-CSF increased the biochemical pregnancy rate (RR = 2.12; 95% CI: 1.54, 2.93), the embryo implantation rate (RR = 2.51; 95% CI: 1.82, 3.47) and the clinical pregnancy rate (RR = 1.93; 95% CI: 1.63, 2.29) in patients with a history of repeated implantation failure undergoing IVF. No differences were found in pregnancy outcomes of general IVF patients.

CONCLUSIONS

Granulocyte colony-stimulating factor is likely to be a potential option for infertility women undergoing IVF with thin endometrium or recurrent implantation failure .

TRIAL REGISTRATION

Retrospectively registered (The PROSPERO registration number: CRD42022360161).

Granulocyte colony stimulating factor versus human chorionic gonadotropin for recurrent implantation failure in intra cytoplasmic sperm injection: a randomized clinical trial

BACKGROUND

Repeated implantation failure (RIF) is defined as the case whereby the transferred embryos fail to implant after several attempts of In vitro fertilization (IVF) which causes a profound impact on the quality of life and financial burden. Some clinical studies have confirmed that Granulocyte colony-stimulating factor (G-CSF) and human chorionic gonadotropin (HCG) can improve pregnancy outcomes and implantation rates. Hence, our study aims to compare the efficacy of G-CSF and HCG on pregnancy outcomes in RIF women who undergo intra-cytoplasmic sperm injection (ICSI).

METHODS

This randomized, single-blinded study was conducted et al.-Azhar University Hospitals, Cairo, Egypt, between 10^th October 2020 and 20^th December 2020. The study included 100 women aged 20-43 years old undergoing ICSI cycles, with a history of RIF. Patients were divided randomly into two groups: group (1): included 50 patients injected with 500 IU of intrauterine HCG on embryo transfer day, and group (2): Included 50 patients injected with G-CSF on the embryo transfer day.

RESULTS

In 100 RIF women, we found a significant improvement in pregnancy outcomes favoring G-CSF over HCG including implantation rate, chemical pregnancy, and clinical pregnancy (P < 0.0001, P = 0.0003, and P = 0.0006, respectively).

CONCLUSION

For the first time, we demonstrated a significant improvement in pregnancy outcomes favoring G-CSF over HCG in terms of implantation rate, chemical pregnancy, and clinical pregnancy.

TRIAL REGISTRATION

The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202010482774275 and was approved on 2^nd October 2020.

Granulocyte colony-stimulating factor in reproductive-related disease: Function, regulation and therapeutic effect

Granulocyte colony-stimulating factor (G-CSF) is one of the cytokines which plays important roles in embryo implantation and normal pregnancy. At the maternal-fetal interface, G-CSF can be synthesized by multiple cells, and participates in regulation of trophoblast development, endometrial decidualization, placental metabolism and angiogenesis. Moreover, as an important medium of intercellular communication, G-CSF has also been shown to exert key roles in crosstalk between cellular components at the maternal-fetal interface. Recently, our study demonstrated that G-CSF derived from M2 macrophage could promote trophoblasts invasion and migration through activating PI3K/AKT/Erk1/2 pathway, thereby involving in normal pregnancy program. Herein, we will summarize the role and regulation of G-CSF in normal pregnancy and reproductive-related disease, and the clinical applications of G-CSF in patients undergoing in vitro fertilization with thin endometrium, repeated implantation failure, and women suffered with recurrent spontaneous abortion.

Is there any difference between the obstetric and perinatal complications of pregnancy in patients with and without repeated implantation failure in fresh and frozen-thawed embryo transfer cycles?

Background

Repeated implantation failure (RIF) is the main challenge in assisted reproduction; the present study aimed to compare the obstetric and perinatal outcomes between RIF and control patients who experienced a successful pregnancy after fresh embryo transfer (ET) or frozen-thawed embryo transfer (FET) cycles. Data were obtained from 1150 women experiencing embryo transfer(s), consisting of 720 fresh ET and 430 FET cycles, at the Research and Clinical Center for Infertility, Yazd, Iran. The 370 women, in total, reached chemical pregnancies and finally 321 cases in fresh ET (n=216) and FET (n=105) cycles with singleton deliveries divided into two groups of control and RIF according to the number of last implantation failures. Then, the rate of obstetric and prenatal complications was compared between two groups in fresh ET and FET cycles.

Results

The results showed a higher abortion rate in the RIF group compared to the control group in fresh and FET cycles. In the assessment of the data from the cases with singleton pregnancies in fresh and FET cycles, the results showed almost similar obstetric and perinatal complications in the patients of RIF and control groups. Although the rates of some complications like vaginal bleeding, PROM, preterm delivery, and NICU administration were higher in the RIF patients, these were not significant (P > 0.05).

Conclusion

There was some variation in the normal rates of obstetric and perinatal outcomes between RIF patients compared to control. But, it seems necessary to run studies on more patients to endorse this conclusion.

What is the impact of granulocyte colony-stimulating factor (G-CSF) in subcutaneous injection or intrauterine infusion and during both the fresh and frozen embryo transfer cycles on recurrent implantation failure: a systematic review and meta-analysis?

BACKGROUND

Among recurrent implantation failure (RIF) patients, the rate of successful implantation remains relatively low due to the complex etiology of the condition, including maternal, embryo and immune factors. Effective treatments are urgently needed to improve the outcomes of embryo transfer for RIF patients. In recent years, many researchers have focused on immunotherapy using granulocyte colony-stimulating factor (G-CSF) to regulate the immune environment. However, the study of the G-CSF for RIF patients has reached conflicting conclusions. The aim of this systematic review and meta-analysis was performed to further explore the effects of G-CSF according to embryo transfer cycle (fresh or frozen) and administration route (subcutaneous injection or intrauterine infusion) among RIF patients.

METHOD

The PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for literature published from the initial to October 2020. The meta-analysis, random-effects model and heterogeneity of the studies with I² index were analyzed. Stata 15 was used for statistical analysis.

RESULTS

A total of 684 studies were obtained through the databases mentioned above. Nine RCTs included 976 RIF patients were enrolled in this meta-analysis. Subgroup analysis indicated that G-CSF improved the clinical pregnancy rate for both the fresh and frozen embryo transfer cycles (fresh RR: 1.74, 95% CI: 1.27-2.37, I² = 0.0%, n = 410; frozen RR: 1.44, 95% CI: 1.14-1.81, I² = 0.0.%, n = 366), and for both subcutaneous injection and intrauterine infusion (subcutaneous RR: 1.73, 95% CI: 1.33-2.23, I² = 0.0%, n = 497; intrauterine RR: 1.39, 95% CI: 1.09-1.78, I² = 0.0%, n = 479), but the biochemical pregnancy rate of the RIF group was also higher than that of the control group (RR: 1.85, 95% CI: 1.28-2.68; I² = 20.1%, n = 469). There were no significant differences in the miscarriage rate (RR: 1.13, 95% CI: 0.25-5.21: I² = 63.2%, n = 472) and live birth rate (RR: 1.43, 95% CI: 0.86-2.36; I² = 52.5%; n = 372) when a random-effects model was employed.

CONCLUSION

The administration of G-CSF via either subcutaneous injection or intrauterine infusion and during both the fresh and frozen embryo transfer cycles for RIF patients can improve the clinical pregnancy rate. However, whether G-CSF is effective in improving livebirth rates of RIF patients is still uncertain, continued research on the utilization and effectiveness of G-CSF is recommended before G-CSF can be considered mainstream treatment for RIF patients.

Diagnostic and therapeutic options in recurrent implantation failure

Recurrent implantation failure (RIF) is an uncommon, imprecisely defined clinical disorder characterized by failure to achieve pregnancy after repeated embryo transfers. The diverse etiologies and incomplete understanding of RIF provide significant diagnostic and therapeutic challenges to patients and providers. 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. Undetected, small polyps or small areas of intrauterine synechiae are relatively common and easily treated contributors to RIF. Molecular and cellular abnormalities pose a greater therapeutic challenge. Putative causes of RIF, including progesterone resistance, shifted window of receptivity, decreased integrin expression, and immunologic disturbances, should be considered in the evaluation of a patient with otherwise unexplained RIF. It may also be true that a more complex and standardized definition of RIF would be helpful in these cases. In this paper, we review the diagnostic and therapeutic approaches to RIF, with emphasis on disorders of endometrial receptivity.