High pregnancy rates with administration of granulocyte colony-stimulating factor in ART-patients with repetitive implantation failure and lacking killer-cell immunglobulin-like receptors

[Effect of Intrauterine Perfusion of Granulocyte Colony-Stimulating Factor on Endometrium and Blood Flow Parameters in Patients With Thin Endometrium: A Prospective Controlled Clinical Trial]

Objective

To investigate the effects of intrauterine perfusion with granulocyte colony-stimulating factor (G-CSF) on the endometrial thickness, volume, and blood flow parameters of patients with thin endometrium and their clinical outcomes.

Methods

We designed a prospective non-randomized synchronous controlled trial and recruited patients with thin endometrium who underwent frozen-thawed embryo transfer (FET) at Mianyang Central Hospital between September 1, 2021 and September 1, 2023. They were divided into two groups, an experimental group of patients who received the experimental treatment of intrauterine perfusion with G-CSF and a control group of patients who did not receive the experimental treatment. The general data and the clinical outcomes of the two groups were analyzed and compared. The endometrial thickness, volume and blood flow parameters of patients in the experimental group before and after intrauterine perfusion with G-CSF were analyzed.

Results

The clinical data of 83 patients were included in the study. The experimental group included 51 cases, while the control group included 31 cases. There were no significant differences in the baseline data between the two groups. The clinical pregnancy rate of the experimental group (56.86%) was higher than that of the control group (50.00%) and the rate of spontaneous abortion in the experimental group (27.59%) was lower than that in the control group (37.50%), but the differences were not statistically significant (P>0.05). In the experimental group, the postperfusion endometrial thickness ([0.67±0.1] cm) was greater than the preperfusion endometrial thickness ([0.59±0.09] cm), the postperfusion ([1.84±0.81] cm3) was greater than the preperfusion endometrial volume ([1.54±0.69] cm3), and the postperfusion vascularization flow index (VFI) (1.97±2.82) was greater than the preperfusion VFI (0.99±1.04), with all the differences being statistically significant (P<0.05).

Conclusion

Intrauterine perfusion with G-CSF can enhance the endometrial thickness, volume, and some blood flow parameters in patients with thin endometrium.

Immunological Aspects of Infertility-The Role of KIR Receptors and HLA-C Antigen

The mechanisms of immune tolerance of a mother against an antigenically foreign fetus without a concomitant loss of defense capabilities against pathogens are the factors underlying the success of a pregnancy. A significant role in human defense is played by killer immunoglobulin-like receptor (KIR) receptors, which regulate the function of the natural killer (NK) cells capable of destroying antigenically foreign cells, virus-infected cells, or tumor-lesioned cells. A special subpopulation of NK cells called uterine NK cells (uNK) is found in the uterus. Disruption of the tolerance process or overactivity of immune-competent cells can lead to immune infertility, a situation in which a woman's immune system attacks her own reproductive cells, making it impossible to conceive or maintain a pregnancy. Since the prominent role of the inflammatory response in infertility, including KIR receptors and NK cells, has been postulated, the process of antigen presentation involving major histocompatibility complex (MHC) molecules (HLA) appears to be crucial for a successful pregnancy. Proper interactions between KIR receptors on female uNK cells and HLA class I molecules, with a predominant role for HLA-C, found on the surface of germ cells, are strategically important during embryo implantation. In addition, maintaining a functional balance between activating and inhibitory KIR receptors is essential for proper placenta formation and embryo implantation in the uterus. A disruption of this balance can lead to complications during pregnancy. The discovery of links between KIR and HLA-C has provided valuable information about the complexity of maternal-fetal immune interactions that determine the success of a pregnancy. The great diversity of maternal KIR and fetal HLA-C ligands is associated with the occurrence of KIR/HLA-C combinations that are more or less favorable for reproductive success.

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.

Granulocyte colony-stimulating factor priming improves embryos and pregnancy rate in patients with poor ovarian reserve: a randomized controlled trial

BACKGROUND

Granulocyte colony-stimulating factor (G-CSF) administration increased ovarian preantral follicles and anti-Müllerian hormone (AMH) in animal models with diminished ovarian reserve. We investigated whether G-CSF priming before treatment with assisted reproductive technology (ART) improved embryo development and pregnancy rate while increasing serum AMH in patients with poor ovarian reserve.

METHODS

In this prospective randomized open-label controlled trial, 100 patients 20 to 42 years old with AMH below 2 ng/mL were randomized to priming or control groups (50 patients each). None had over 1 ART failure, day-3 follicle-stimulating hormone (FSH) above 30 IU/L, uterine anomalies, or a partner with azoospermia. All patients initially underwent conventional infertility treatment for 2 consecutive cycles in which the priming group but not controls received a subcutaneous G-CSF priming injection during the early luteal phase. Each group then underwent 1 cycle of in vitro fertilization/intracytoplasmic sperm injection and fresh embryo transfer (IVF/ICSI-fresh ET), followed by cryopreserved ET if needed until live birth or embryo depletion. AMH was measured before and after priming.

RESULTS

Fertilization rate, embryonic development, and implantation rate by fresh ET were significantly improved by priming. Clinical and ongoing pregnancy rates by IVF/ICSI-fresh ET were significantly higher with priming (30% and 26% in 47 ART patients; 3 delivered with conventional treatment) than in controls (12% and 10% in 49 ART patients; 1 dropped out). With priming, significantly more patients achieved cryopreservation of redundant blastocysts. The cumulative live birth rate was 32% in 50 patients with priming, significantly higher than 14% in 49 controls (relative risk, 2.8; 95% confidence interval, 1.04-7.7). Infants derived from priming had no congenital anomalies, while infant weights, birth weeks, and Apgar scores were similar between groups. Among 4 variables (age, day-3 FSH, AMH, and priming), logistic regression significantly associated age and priming with cumulative live birth. Priming significantly increased serum AMH. No adverse effects of priming were observed.

CONCLUSION

G-CSF priming improved embryonic development and pregnancy rate during ART treatment and increased AMH in patients with poor ovarian reserve. Enhanced preantral follicle growth likely was responsible.

TRIAL REGISTRATION

UMIN registration in Japan (UMIN000013956) on May 14, 2014.  https://www.umin.ac.jp/ctr/index.htm .

Efficacy of intrauterine infusion therapy before embryo transfer in recurrent implantation failure: A systematic review and network meta-analysis

Previous studies of intrauterine infusion therapy in recurrent implantation failure (RIF) patients have shown conflicting results, and there is a lack of head-to-head horizontal comparisons between different drugs. This study aimed to assess the effectiveness of four intrauterine infusion drugs, including human chorionic gonadotropin (HCG), granulocyte colony-stimulating factor (G-CSF), peripheral blood mononuclear cells (PBMCs) and autologous platelet-rich plasma (PRP), in improving pregnancy outcomes in RIF patients through the network meta-analysis. Randomized controlled trials (RCTs) of preimplantation intrauterine infusion for RIF were searched in the Cochrane Library, Embase, Medline and CINAHL. Meanwhile, relevant data were extracted and Stata 15.0 software was applied to statistical analysis. A total of 21 studies with a sample size of 2917 cases were included in this study. Clinical pregnancy rate network meta-analysis showed that, intrauterine infusion of all four drugs is significantly better than the blank and placebo groups, while only PRP could significantly increase live birth rate compared with the blank and placebo groups. The SUCRA plots of clinical pregnancy and live birth rates showed a higher ranking of PRP and PBMCs. Early abortion intervention analysis found that only G-CSF is significantly better than the blank and placebo groups, and the SUCRA plot of G-CSF showed the highest ranking. All these findings confirmed that all four intrauterine infusion drugs can improve pregnancy outcomes in RIF patients to varying degrees, with PRP being the most effective. Further prospective, large-scale and high-quality RCTs are still necessary to determine the exact subgroups of benefit for the different drugs.

Recurrent implantation failure: A comprehensive summary from etiology to treatment

Implantation is the first step in human reproduction. Successful implantation depends on the crosstalk between embryo and endometrium. Recurrent implantation failure (RIF) is a clinical phenomenon characterized by a lack of implantation after the transfer of several embryos and disturbs approximately 10% couples undergoing in vitro fertilization and embryo transfer. Despite increasing literature on RIF, there is still no widely accepted definition or standard protocol for the diagnosis and treatment of RIF. Progress in predicting and preventing RIF has been hampered by a lack of widely accepted definitions. Most couples with RIF can become pregnant after clinical intervention. The prognosis for couples with RIF is related to maternal age. RIF can be caused by immunology, thrombophilias, endometrial receptivity, microbiome, anatomical abnormalities, male factors, and embryo aneuploidy. It is important to determine the most possible etiologies, and individualized treatment aimed at the primary cause seems to be an effective method for increasing the implantation rate. Couples with RIF require psychological support and appropriate clinical intervention. Further studies are required to evaluate diagnostic method and he effectiveness of each therapy, and guide clinical treatment.

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 Role for Granulocyte Colony Stimulating Factor in Improvement of Implantation in Intrauterine Insemination? A Prospective Double-Blind Randomized Control Trial

BACKGROUND

Granulocyte colony stimulating factor (GCSF) has been introduced as an immunomodulatory agent by increasing implantation rate in vitro fertilization (IVF) patients but it has not been studied in intrauterine insemination (IUI) patients. The aim of this study is to answer the role of GCSF in implantation rate of IUI.

MATERIALS AND METHODS

In this prospective double-blind randomized control trial, 320 eligible patients were enrolled, who were referred to the referral infertility clinic of Shiraz University of Medical Sciences from February 2018 till the end of 2019. They were divided into two groups randomly. After collecting the demographic data, all patients received clomiphene citrate from the 5th day of the menstruation cycle for 5 days. 50-150 units of recombinant purified follicle-stimulating factor (FSH) were started from the 8th day of the cycle. Follicle monitoring was done by transvaginal sonography till a mature follicle of 18 mm or more was developed. Human chorionic gonadotropin (HCG) injection was done in both groups with intrauterine administration of 300 μg GCSF in the case group and normal saline in the control group simultaneously. After 36 hours, IUI was performed. The clinical pregnancy, miscarriage, and ongoing pregnancy rates of both groups were calculated by SPSS software.

RESULTS

The results showed improvement of clinical pregnancy rate [15.38% vs. 13.81% OR=1.17 (0.62-2.21)], miscarriage rate [3.84% vs. 5.26% OR=0.74 (0.25-2.20)] and ongoing pregnancy rate [11.53% vs. 8.55% OR=1.37 (0.65-2.92)] in the GCSF group compared to the control. However, the results revealed no statistically significance (P>0.05).

CONCLUSION

Although it was not statistically significant, 300 μg Intrauterine GCSF administration simultaneously with hCG injection in standard IUI procedure might increase the pregnancy outcomes. Further studies are warranted (registration number: IRCT201212079281N2).

Human Decidual Stromal Cells in Early Pregnancy Induce Functional Re-Programming of Monocyte-Derived Dendritic Cells via Crosstalk Between G-CSF and IL-1β

Accumulation of dendritic cells (DCs) is a special characteristic of the decidual microenvironment. Decidua-infiltrated DCs show unique phenotypes and functions that promote the establishment of fetal-maternal tolerance. However, the regulatory mechanisms yet to be fully investigated. Decidual stromal cells (DSCs) are the major cellular component of decidua tissue. The interactions between DSCs and decidua-infiltrated immunocytes dictate immune tolerance in early pregnancy. Therefore, in the present study, we explore the effect of early pregnancy DSCs on monocyte-derived DCs and the relevant mechanisms. DSC-conditioned DCs showed altered phenotypes, secretion profiles and Th2 priming potential. G-CSF concentration was significantly up-regulated in the co-culture supernatant between DSCs and DCs. Supplementation of G-CSF neutralizing antibody partly reversed the reprogramming of DCs mediated by DSCs. Furthermore, G-CSF production was promoted by IL-1β, which was mainly produced by DCs and significantly up-regulated after their cultivation with DSCs. Interestingly, the effects of DSC on IL-1β production of DCs occurred in their immature stage but not their mature stage. Lastly, no significant difference of G-CSF was found in DSCs from healthy early pregnancy women and spontaneous abortions (SA) patients. However, DSCs from SA patients secreted less G-CSF in response to exogenous rhIL-1β or DC cultivation. In conclusion, our study bolster the understanding of the decidual immunomodulatory microenvironment during early pregnancy, and brings new insight into the potential clinical value of G-CSF in pregnancy disorders.

The intrauterine perfusion of granulocyte-colony stimulating factor (G-CSF) before frozen-thawed embryo transfer in patients with two or more implantation failures

The objective of this study was to investigate the clinical benefits of intrauterine perfusion with G-CSF in patients undergoing a frozen-thawed embryo transfer (FET) after at least two previous implantation failures. This was a prospective, randomized, single-blind study. The intervention group received an intrauterine infusion of G-CSF whereas the placebo group was given an intrauterine infusion of physiological saline before embryo transfer. A third (control) group did not receive an intrauterine infusion prior to embryo transfer. The clinical pregnancy rates of both the intervention and placebo group were significantly higher than that in the control group (p < 0.05). But the miscarriage rates of the G-CSF were significantly lower than those of the other two groups (p < 0.05). The intrauterine infusion of G-CSF before frozen-thawed embryo transfer significantly reduced miscarriage rates and improve the live birth rates. While intrauterine perfusion with physiological saline did not reduce miscarriage rates.

Treatment of G-CSF in unexplained, repeated implantation failure: A systematic review and meta-analysis

BACKGROUD

Repeated implantation failure (RIF) is a stressful situation for subfertile women undergoing in vitro fertilisation (IVF) treatment and caregivers. Granulocyte-colony stimulating factor (G-CSF) seems to play an important role in assisted reproductive techniques. However, it is currently unknown whether G-CSF is effective in improving results for patients with RIF.

OBJECTIVE

To describe and summarize current evidence of the effect of the granulocyte colony stimulating factor (G-CSF) in treating RIF.

METHOD

Relevant scientific literature was thoroughly searched by computer in domestic and foreign database from the inceptions to November 2019. And relevant randomized controlled trials (RCTs) assessing the efficacy of G-CSF in unexplained RIF were included. The meta-analysis was conducted by Stata 12. 0 software, and we estimated relative risks (RRs) and associated 95 % confidence intervals (CIs) of G-CSF on implantation rate (IR), the clinical pregnancy rate (CPR), the abortion rate (AR) in patients with unexplained RIF using fixed-effect model. Besides, Subgroup analysis was performed according to the different administration methods.

RESULT

A total of eleven articles were included for the final meta-analysis with sample sizes ranging from 13 to 107 patients. The G-CSF was associated with an increased IR [RR = 2.346, 95 %CI (1.615-3.409), I2 = 0. 0%] and CPR [RR = 1.910, 95 %CI (1.562-2.337), I2 = 0.0 %] in patients with unexplained RIF. When further stratified by the method of administration, the subgroup analysis revealed that both intrauterine injection and subcutaneous injection are capable of improving IR[subcutaneous injection:RR = 2.400, 95 %CI (1. 268-4. 542), I2 = 0.0 %; intrauterine injection:RR = 2.317, 95 %CI (1.462-3.673), I2 = 0.0 %] and CPR[subcutaneous injection: RR = 2. 022, 95 %CI (1.443-2.832), I2 = 0. 0%; intrauterine injeciton: RR = 1.848, 95 %CI (1.438-2.376), I2 = 0. 0%]. G-CSF was not associated with AR in patients with unexplained RIF [RR = 2.092, 95 %CI (0.815-5.369), I2 = 0.0 %].

CONCLUSION

The current evidence support G-CSF's positive effect on the implantation rate and clinical pregnancy rate of patients with unexplained RIF, especially when administrated by subcutaneous injection. There is no conclusive evidence for the association between G-CSF and the abortion rate. Moreover, few of the included articles reported side effects of G-CSF, so its safety remains to be investigated.Thus, future research should evaluate.

Evaluation of granulocyte colony-stimulating factor on the treatment of thin endometrium during frozen-thawed embryo transfer cycles: a retrospective cohort study

The aim of this study was to evaluate the effect of granulocyte colony-stimulating factor (G-CSF) on thin endometrium (≤7 mm) in women undergoing frozen-thawed embryo transfer (FET). This retrospective cohort study includes 271 infertile patients with thin endometrium. 117 patients who received intrauterine perfusion of G-CSF before the day of administration of progesterone were defined as G-CSF group, whereas 154 patients who refused to use G-CSF treatment were defined as control group. In the G-CSF group, significantly higher endometrial thickness was observed after G-CSF perfusion (p < .001). When we divided the G-CSF group into two subgroups according to whether they conceived, the endometrial thickness increased from 6.02 ± 0.92 mm to 6.98 ± 1.20 mm in the conception group (p < .001) and from 6.21 ± 0.96 mm to 6.87 ± 1.16 mm in the non-conception group (p < .001). However, there were no significant differences between the two subgroups in respect to the endometrial thickness both before and after G-CSF perfusion. The implantation rate, hCG positive rate and clinical pregnancy rate were similar between G-CSF group and control group. Thus, our study fails to demonstrate that G-CSF has the potential to improve pregnancy outcome but has the potential to increase endometrial thickness of the women with thin endometrium in FET cycles.

The incidence rate of unresponsive thin endometrium in frozen embryo transfer cycles: A case-series of therapy with granulocyte colony stimulating factor

Background

Treatment-resistant thin endometrium (TTE) during in-vitro fertilization is a relatively uncommon and challenging problem.

Objective

The primary aim of the study was to assess the TTE rate during frozen embryo transfer (FET) cycles and the secondary aim was to evaluate the effect of intrauterine instillation of granulocyte colony stimulating factor (G-CSF) in these cases.

Materials and Methods

In this cross-sectional study, all of the women who underwent FET cycles with hormonal endometrial preparation in Royan Institute from June 2015 to March 2018 were evaluated and all of the cases with TTE diagnosis (endometrial thickness < 7 mm after using high doses of estradiol) were included. In the eligible cases, 300 μgr of G-CSF was infused intrauterine. If the endometrium had not reached at least a 7-mm, a second infusion was prescribed within 48 hr later.

Results

During the study, 8,363 of FET cycles were evaluated and a total of 30 infertile patients (0.35%) with TTE diagnosis were detected. Finally, 20 eligible patients were included. The changes of endometrial thickness after G-CSF therapy were significant (p < 0.001); however, the endometrial thickness did not reach 7 mm in nine patients (45%) and the embryo transfer was canceled.

Conclusion

It was found that the rate of TTE during the FET cycle is very low and intrauterine perfusion of G-CSF has a potential effect to increase the endometrial thickness in these patients; however, the rate of cancellation was still high and poor pregnancy outcomes were observed.

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

The aim of this study was to assess whether the dual administration of granulocyte colony-stimulating factor (G-CSF) increases the effect of only systemic administration in patients with RIF. This retrospective study included 111 infertile normoresponder cases with two or more unsuccessful in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) treatments, despite the transfer of good quality embryos. Patients were divided into three groups according to using G-CSF and administration route; Group 1 included patients who received subcutaneous (SC) G-CSF only (n = 38), Group 2 comprised patients who received both intrauterine (IU) and SC G-CSF (n = 39), the control group included patients who did not receive G-CSF who were matched by age (n = 34). The IU route of G-CSF was employed on ovulation triggering day. G-CSF was administered via an IU insemination catheter. SC injection was started on the day of oocyte retrieval and administered for 15 days at 100,000 IU/kg. Foetal cardiac activity (clinical pregnancy) was present in 50 patients (46.2%) after embryo transfer, with 20 patients included in SC group (Group 1) (52.6%), 25 in SC + IU group (Group 2) (64.1%) and 8 (23.5%) in control group and significant difference was observed between groups (p: .001). Pregnancy resulted in live birth in 43 patients (39.8%), with 13 patients belonging in Group 1 (34.2%), 25 in Group 2 (61.5%) and 8 (23.5%) in control group; significant differences were observed between groups (p: .001). In conclusion, our results showed that dual administration of G-CSF was significantly more effective that the SC only method.Impact statementWhat is already known on this subject? A number of studies reported the possible benefits of granulocyte colony-stimulating factor (G-CSF) administration in recurrent implantation failure (RIF) and recurrent pregnancy loss patients; however, it is unclear which administration route is better.What do the results of this study add? Our results showed that G-CSF is a promising and safe agent for increasing live birth rates in patients with RIF. Additionally, dual administration is considered the better method than SC only administration.What are the implications of these findings for clinical practice and/or further research? Clinicians should consider a combination of IU use before ovulation triggering with SC administration starting from the day of oocyte collection for using G-CSF for the treatment of recurrent implantation failure. Additionally, our data show the need for research in the field of administration route of G-CSF for RIF. We suggest that further studies be performed in this field.

JG. New therapeutic protocol for improvement of endometrial receptivity (PRIMER) for patients with recurrent implantation failure (RIF) - A pilot study

OBJECTIVE

To evaluate whether or not one should use a new Protocol for Endometrial Receptivity Improvement (PRIMER) based on platelet-rich plasma (PRP) and granulocyte colony-stimulation factor (G-CSF) to enhance ongoing pregnancy rates in patients with recurrent implantation failure (RIF).

METHODS

Women undergoing IVF/ICSI were prospectively divided into two groups: - PRIMER/RIF group (n:33): patients with RIF (defined as ≥2embryo transfers (ETs) and at least 5 morphologically good embryos transferred) in which intrauterine PRP injection and subcutaneous G-CSF-injection were performed. - Control group (n:33): patients in their first IVF/ICSI attempt/cycle (without PRP or G-CSF injection). The PRP was prepared using autologous fresh-whole blood processed to increase platelet-concentration in 2 to 4 fold. All patients undergoing the PRP-treatment received 0.7ml of it through intrauterine-injection 48 hours before the ET. G-CSF (300mg/0.5ml) started simultaneously to PRP and was administered subcutaneously every week.

RESULTS

Regarding implantation, clinical pregnancy and miscarriage rates, we found no statistically significant difference (18.2% versus 17.6%, p=0.90; 36.4% versus 30.3%, p=0.61 and 25.0% versus 9.0%, p=0.43, respectively). The use of PRIMER enabled RIF patients (previous ET µ: 4.0±1.5) to reach similar ongoing pregnancy and live birth rates like those patients who had their first IVF/ICSI cycle attempt (27.3% versus 27.3%, p=0.99).

CONCLUSIONS

Our results showed, for the first time, evidence that this therapeutic protocol (PRIMER) could be used as a feasible treatment based on biological rationale for patients with RIF, considering its promising outcomes, it is a simple procedure and not associated with patient complications.

Mediator in the Embryo-endometrium Cross-talk: Granulocyte Colony-stimulating Factor in Infertility

Successful implantation requires a receptive endometrium and a good quality egg. The challenges a physician encounters with regard to this in assisted reproductive technology are obtaining good quality embryo, achieving optimal endometrial thickness (EMT), and subsequently implantation, which is denotive of a receptive endometrium. Granulocyte colony-stimulating factor (G-CSF) has been observed to be a biomarker of oocyte quality and has been shown to enhance EMT and implantation because of its immunological effects. A systematic search for all relevant articles on G-CSF in follicular fluid and its therapeutic benefit in thin endometrium and recurrent implantation failure was performed, and peer-reviewed, full-text articles related to humans were included in the study. As a tool to determine the potentiality of oocyte, G-CSF shows promise with its predictability increasing in combination with morphological embryo scoring or interleukin 15. For the thin endometrium, G-CSF is especially useful in patients who are refractory to other treatment modalities. In recurrent implantation failure (RIF), G-CSF showed potential in a subset of patients with immunological deficiency lacking killer cell immunoglobulin-like receptor genes. This review highlights the various forms of usage of G-CSF and the effectiveness of G-CSF in infertility. G-CSF equips embryologists with a tool to determine the potentiality of oocyte and physicians with therapy for thin endometrium and RIF, especially since the available treatment options are ineffective.

Comparing the Impact of Autologous Platelet-rich Plasma and Granulocyte Colony Stimulating Factor on Pregnancy Outcome in Patients with Repeated Implantation Failure

BACKGROUND

Despite the advancements in assisted reproductive technologies, repeated implantation failure (RIF) still remains a challenging problem for patients and clinicians. The aim of the present study was to compare the impact of intrauterine infusion of autologous platelet-rich plasma (PRP) and systemic administration of granulocyte colony stimulating factor (GCSF) on pregnancy outcome in patients with repeated implantation failure.

METHODS

The present retrospective cohort study included 123 patients with history of more than two repeated failed embryo transfers. Cycles were divided into two groups of intrauterine infusion of PRP (n=67) and systemic administration of GCSF (n=56). Pregnancy outcome was compared between two groups. The p-value less than 0.05 was considered statistically significant.

RESULTS

The clinical pregnancy rate was significantly higher in PRP group than GCSF group (40.3% versus 21.4%, p=0.025). The crud and adjusted odds ratios (95% confidence interval (CI)) were 2.5 and 2.6 (p=0.025, CI: 1.11-5.53 and p=0.03, CI: 1.10-6.15), respectively.

CONCLUSION

It seems that intrauterine infusion of PRP can positively affect pregnancy outcome in RIF patients in comparison with systemic administration of GCSF and more studies need to be designed to conclude the effectiveness of this method.

The Effects of Subcutaneous Administration of Granulocyte Colony-Stimulating Factor on Pregnancy Outcome After Assisted Reproductive Technology: Clinical Trial

Background: Granulocyte-colony stimulating factor (G-CSF) is an innovative therapy in reproductive medicine. Although its mechanisms of action have remained unknown, G-CSF seems to be effective in the case of recurrent abortion or implantation failure and thin endometrium. Objectives: This study was conducted to investigate whether subcutaneous administration of G-CSF has any effect on pregnancy outcome after assisted reproductive technology (ART). Methods: Fifty women with male infertility factors undergoing ART treatment were enrolled and stimulated with the standard long protocol. The G-CSF group of women received one dose of subcutaneous G-CSF (Filgrastim, 300 µg/1 mL) on the day of embryo transfer and again two days later while the placebo group received normal saline. Results: Seventeen patients had a positive β-human chorionic gonadotropin concentration after embryo transfer (8 and 9 in G-CSF and placebo groups, respectively) although the difference was not statistically significant. In addition, spontaneous abortion occurred in three patients (1 patient in the G-CSF group vs. 2 patients in the placebo group). Conclusion: Overall, although G-CSF failed to affect the endometrial thickness, as well as implantation, or clinical pregnancy rates, a lower prevalence of abortion in G-CSF group may be due to the positive effect of G-CSF administration on the endometrium as compared to the placebo group.

Assessment of potential biomarkers of pre-receptive and receptive endometrium in uterine fluid and a functional evaluation of the potential role of CSF3 in fertility

The endometrium lines a women's uterus becoming receptive, and allowing embryo implantation to occur, for just a few days during the post-ovulatory mid-secretory phase of each menstrual cycle. We investigated whether concentrations of proposed receptivity biomarkers (VEGF, IL8, FGF2, CSF3 sFlt-1, sGP130 and PlGF) secreted by the endometrium into the uterine cavity and forming the microenvironment for embryo implantation is altered among a population of age-matched women with unexplained (idiopathic) infertility compared to fertile women during the receptive mid-secretory phase (n = 16 fertile, 18 infertile) and the prior pre-receptive early secretory phase (n = 19 fertile, 18 infertile) of their cycle. In the mid-secretory cohort significantly elevated concentrations of five biomarkers; PlGF (p = 0.001), IL8 (p = 0.004), sGP130 (p = 0.009), sFlt-1 (p = 0.021), and CSF3 (p = 0.029) was present in uterine fluid of infertile women during the mid-secretory phase, but only CSF3 was significantly elevated in the pre-receptive early secretory phase (p = 0.006). In vitro studies of glycosylated and non-glycosylated forms of CSF3 at representative fertile (20 ng/mL) and infertile (70 ng/mL) effects on endometrium and embryo behaviour were performed. Non-glycosylated CSF3 at fertile concentrations significantly (p < 0.001) elevated endometrial epithelial cell proliferation however chronic treatment or elevated (infertile) concentrations of CSF3 in glycosylated form abrogated the positive effects. Both forms of CSF3 increased trophoblast cell invasion (p < 0.001) regardless of concentration. Mouse embryo outgrowth was significantly (p < 0.01) increased at fertile but not at infertile concentrations. The study confirmed potential utility of five biomarkers of endometrial receptivity for future application in the mid-secretory phase while highlighting CSF3 is elevated in the earlier pre-receptive phase. Our data provides evidence that CSF3 acts on both human endometrium and embryo in a manner that is concentration and glycosylation dependent.

Granulocyte-colony stimulating factor may improve pregnancy outcome in patients with history of unexplained recurrent implantation failure: An RCT

BACKGROUND

Family of colony-stimulating factors (CSF) have an essential role on early cross talk between embryo and uterine endometrium.

OBJECTIVE

The aim of this study was to evaluate the effects of the single dose of Granulocyte-CSF (G-CSF) injection on clinical outcome of assisted reproductive technology cycle in patients with repeated implantation failures.

MATERIALS AND METHODS

This randomized control trial study was performed on 52 infertile women who referred to the clinic with the history of more than three previous In vitro fertilization/Intracytoplasmic sperm injection-embryo transfer failures. All patients were stimulated with standard long protocol. All embryos were transferred on day five in blastocyst stage in both groups. The treated group received 300 µg (0.5 ml) recombinant human G-CSF subcutaneously which was injected 30 min before blastocyst embryo transfer.

RESULTS

There was not statistically significant differences in abortion rate in G-CSF and control group (p=0.09). G-CSF treated group showed higher clinical pregnancy rate in comparison with control group (56.2% vs. 40.0%) but it was not statistically significant (p=0.09). Although live birth rate in G-CSF group was higher than control group (53.1% vs. 35.0%) but there wasn't statistically significant difference in the overall live birth rate between the two groups (p=0.10). G-CSF group had a twin pregnancies while in control group there was no twin pregnancy.

CONCLUSION

Our result demonstrates the possibility that pregnancy outcome is better in women with repeated unexplained In vitro fertilization failure who are treated with G-CSF.

Role of granulocyte colony-stimulating factor in human reproduction

As new research reveals, granulocyte colony-stimulating factor (G-CSF) plays an effective role in pregnancy success, considering that it not only affects the embryo implantation and ovarian function but also it promotes endometrial thickening and improves the pathophysiology of endometriosis, which all fundamentally lead to reducing pregnancy loss. In this review, we focus on the role of G-CSF in human reproduction. We summarized its role in ovulation, luteinized unruptured follicle syndrome, poor responders, improving repeated in vitro fertilization failure, endometrial receptivity and treatment of thin endometrium, and recurrent spontaneous abortion.

Granulocyte colony-stimulating factor gene rs1042658 variant and susceptibility to idiopathic recurrent pregnancy loss: A case-control study

BACKGROUND

Granulocyte colony-in stimulating factor (G-CSF) gene can be a potential candidate gene implicated recurrent pregnancy loss (RPL), a common complication of pregnancy with the prevalence of 1-5% among women of reproductive age.

OBJECTIVE

To investigate the association between rs1042658 polymorphism in the 3' untranslated region (3'UTR) of G-CSF gene and the risk of unexplained RPL among Iranian women.

MATERIALS AND METHODS

In total, 122 women with unexplained RPL and 140 healthy postmenopausal women as a control group were enrolled in this case-control study. Tetra-primer amplification refractory mutation system-polymerase chain reaction was performed to determine the rs1042658 genotypes in all subjects.

RESULTS

Statistically significant differences were detected between the distribution frequencies of both heterozygote CT, and carriage of T allele (TT+CT) genotypes of the rs1042658 between case and control groups. Allelic association was not observed with RPL.

CONCLUSION

Regarding the results of the present study, G-CSF rs1042658 gene polymorphism could be considered as a probable risk factor for unexplained RPL among Iranian women.

KIR, LILRB and their Ligands' Genes as Potential Biomarkers in Recurrent Implantation Failure

Reproductive failure in humans is a very important social and economic problem, because nowadays women decide to conceive later in life and delay motherhood. Unfortunately, with increasing age they have less chance for natural fertilization and maintenance of pregnancy. Many of them need assisted reproductive technology. Approximately 10% of women after in vitro fertilization-embryo transfers experience recurrent implantation failure (RIF). Multiple factors may contribute to RIF, including oocyte and sperm quality, parental chromosomal anomalies, genetic or metabolic abnormalities of the embryo, poor uterine receptivity, immunological disturbances in the implantation site, and some gynecologic pathologies such as endometriosis, uterine fibroids, hydrosalpinx and endometrial polyps. Moreover, the procedure of in vitro fertilization itself could adversely influence the implantation. Nowadays, many studies are focused on the role of natural killer (NK) cells in normal and pathologic pregnancy because NK cells constitute the dominant cell population in the endometrium and they come in close contact with the allogeneic extravillous trophoblast cells in early pregnancy decidua. The majority of these cells are of CD56^bright phenotype. These cells can express killer immunoglobulin-like receptors (KIRs), which, upon recognition of HLA class I molecules (HLA-C and HLA-G) on trophoblasts, may either stimulate or inhibit NK cells to produce soluble factors, and display low cytotoxicity necessary for maintenance of the allogeneic embryo and fetus in the next steps of pregnancy. Moreover, some members of the leukocyte immunoglobulin-like receptor (LILR) family, also named ILT (immunoglobulin-like transcript), are present in the human placenta. LILRB1 (ILT2) was described mainly on stromal cells, while LILRB2 (ILT4), in addition to stromal cells, was also found around vessels in the smooth muscle layer. In this review we focus on the possible role of polymorphism of KIR, LILRB and their ligands (HLA-C, HLA-G) in susceptibility to recurrent implantation failure, which could serve as diagnostic biomarkers of this disease.

Use of granulocyte-colony stimulating factor in assisted reproductive technology: A systematic review and meta-analysis

Granulocyte-colony stimulating factor (G-CSF), a glycoprotein, has been used in women undergoing Assisted Reproductive Technology (ART). We decided to undertake a systematic review to evaluate the effectiveness of G-CSF in women with thin endometrium and recurrent implantation failure (RIF) undergoing ART. The outcomes included an increase in endometrial thickness, live birth, clinical pregnancy rates and adverse effects. We included two trials evaluating women with thin endometrium and another two trials evaluating women with RIF. The pooled data did not reveal statistically significant increase in endometrial thickness following G-CSF in women with thin endometrium (mean difference 0.47, 95% CI -1.36-2.31; I² 82%). However significantly higher clinical pregnancy rate was noted (RR 2.43, 95% CI 1.09-5.40; I² 0%) following G-CSF compared to no intervention and quality of evidence for both these outcomes was very low. In RIF population, the administration of G-CSF was associated with a significantly higher clinical pregnancy rate compared to no intervention with pooled risk ratio of 2.51 (95% CI 1.36-4.63; I² 0%) and quality of evidence being low. Findings of current review suggest a possible benefit of G-CSF in women with thin endometrium undergoing ART and RIF. However these findings need to be further validated in larger trials before G-CSF can be used in routine clinical practice.

Efficacy of Intrauterine Injection of Granulocyte Colony Stimulating Factor (G-CSF) on Treatment of Unexplained Recurrent Miscarriage: A Pilot RCT Study

BACKGROUND

Endometrium undergoes several changes in structure and cellular composition during pregnancy. Granulocyte Colony-stimulating Factor (GCS-F) is an important cytokine with critical role in embryo implantation and pregnancy. The aim of the present study was to evaluate the impact of intrauterine injection of G-CSF in patients who suffer from unexplained recurrent miscarriage (RM).

METHODS

In the present randomized clinical trial, a total of 68 patients were randomly allocated into two study groups including intrauterine G-CSF (n=23, 300 μg) injection and control group (n=27, no G-CSF injection). Eighteen out of 68 patients were excluded from the final analysis due to different reasons. All patients were in Ovulation Induction (I/O) cycle. In G-CSF group, intrauterine injection of G-CSF was done twice in the cycle. All enrolled patients were under 40 years old and had at least two unexplained pregnancy losses. Pregnancy was evaluated by titer of βhCG, presence of gestational sac (implantation) and fetal heart rate (clinical pregnancy) was assessed by vaginal ultrasonography. Student's T test and Mann-Whitney U were used for analysis. The p≤0.05 was determined as statistically significant.

RESULTS

No significant differences were observed between the two study groups when the rates of chemical pregnancy (26.1% vs. 29.6%, p=0.781), implantation (26.1% vs. 22.2%, p=0.750), clinical pregnancy (17.4% vs. 11.1%, p=0.689) and abortion (33% vs. 37.5%, p=0.296) were compared.

CONCLUSION

In our study, no significant difference was observed between the two study groups when the rates of chemical pregnancy, implantation, clinical pregnancy and abortion were compared.

The role of G-CSF in recurrent implantation failure: A randomized double blind placebo control trial

BACKGROUND

Recurrent implantation failure (RIF) is the absence of implantation after three consecutive In Vitro Fertilization (IVF) cycles with transferring at least four good quality embryos in a minimum of three fresh or frozen cycles in a woman under 40 years. The definition and management of RIF is under constant scrutiny.

OBJECTIVE

To investigate the effects of Granulocyte colony stimulating factor (G-CSF) on RIF, pregnancy rate, abortion rate and implantation rates.

MATERIALS AND METHODS

A double blind placebo controlled randomized trial was conducted at two tertiary university based hospitals. One hundred patients with the history of RIF from December 2011 until January 2014 were recruited in the study. G-CSF 300µg/1ml was administered at the day of oocyte puncture or day of progesterone administration of FET cycle. Forty patients were recruited at G-CSF group, 40 in saline and 20 in placebo group.

RESULTS

The mean age for whole study group was 35.3±4.2 yrs (G-CSF 35.5±4.32, saline 35.3±3.98, placebo 35.4±4.01, respectively). Seventeen patients had a positive pregnancy test after embryo transfer [10 (25%) in G-CSF; 5 (12.5%) in saline; and 2 (10%) in placebo group]. The mean of abortion rates was 17.6% (3), two of them in G-CSF, one in saline group. The implantation rate was 12.3% in G-CSF, 6.1% in saline and 4.7% in placebo group.

CONCLUSION

G-CSF may increase chemical pregnancy and implantation rate in patients with recurrent implantation failure but clinical pregnancy rate and abortion rate was unaffected.

Induced Human Decidual NK-Like Cells Improve Utero-Placental Perfusion in Mice

Decidual NK (dNK) cells, a distinct type of NK cell, are thought to regulate uterine spiral artery remodeling, a process that allows for increased blood delivery to the fetal-placental unit. Impairment of uterine spiral artery remodeling is associated with decreased placental perfusion, increased uterine artery resistance, and obstetric complications such as preeclampsia and intrauterine growth restriction. Ex vivo manipulation of human peripheral blood NK (pNK) cells by a combination of hypoxia, TGFß-1 and 5-aza-2'-deoxycytidine yields cells with phenotypic and in vitro functional similarities to dNK cells, called idNK cells. Here, gene expression profiling shows that CD56Bright idNK cells derived ex vivo from human pNK cells, and to a lesser extent CD56Dim idNK cells, are enriched in the gene expression signature that distinguishes dNK cells from pNK cells. When injected into immunocompromised pregnant mice with elevated uterine artery resistance, idNK cells homed to the uterus and reduced the uterine artery resistance index, suggesting improved placental perfusion.

Effects of low doses of mifepristone on human embryo implantation process in a three-dimensional human endometrial in vitro co-culture system

OBJECTIVES

We wanted to explore the effects of two different low doses (0.5μM and 0.05μM) of mifepristone, exposed during the receptive period, on the human embryo implantation process, using a well-established three-dimensional in vitro cell culture model, specifically developed to study this process.

METHODS

An in vitro three-dimensional cell culture model was constructed using human endometrial cells isolated from the endometrium of proven fertile women, collected on cycle day LH+4. After 5 days of culture, supernumerary human embryos were added and cultured for another 5 days with mifepristone 0.5μM (n=8) or 0.05μM (n=10) or vehicle as control (n=10). The cultures were checked for embryo attachment and terminated. We studied the expression of 16 reported endometrial receptivity markers in the endometrial constructs using real-time polymerase chain reaction.

RESULTS

None of the embryos in 0.5μM of mifepristone attached to the endometrial constructs (p=.004), whereas 4 out of 10 in 0.05μM (p=.3698) and 7 out of 10 embryos in the control group attached to the cultures. We found that most of the studied receptivity markers were significantly altered with mifepristone exposure in a similar direction in both treatment groups. Only IL6 was significantly differentially expressed between the treatment groups (p=.017).

CONCLUSION

We report for the first time that exposure to a low concentration (0.5μM) of mifepristone during the receptive period successfully inhibits human embryo implantation process in vitro. Further, we observed a dose-dependent effect of mifepristone on endometrial receptivity at the functional level.

IMPLICATION

This study contributes new knowledge that low dose of mifepristone during the short period of receptive phase can inhibit endometrial receptivity, which further promotes mifepristone as a contraceptive agent. This could give women a treatment choice to avoid unwanted pregnancy with high efficacy and minimal side effects.

Add-ons in IVF programme - Hype or Hope?

A series of new technologies and adjuvant therapies have been advocated in order to improve the success of IVF treatment. Dehydro-epiandrostenedione, growth hormones, Coenzyme Q 10, calcium ionosphores, immune therapy, heparin, low-dose aspirin, and vasodilators are among commonly prescribed pharmacological adjuvants. New technologies that are proposed to improve IVF outcomes include advanced sperm selection procedures, time- lapse embryo monitoring, preimplantation genetic screening, assisted hatching endometrial injury or embryo-glue. This review looked into current evidence to justify the use of these co-interventions and whether some of them can still be offered while awaiting more robust evidence to con rm or refute their role.

Effects of Granulocyte Colony-Stimulating Factor (GCSF) on Persistent Thin Endometrium in Frozen Embryo Transfer (FET) Cycles

OBJECTIVE

To predict the effectiveness of granulocyte colony-stimulating factor (GCSF) in the treatment of persistent thin endometrium resistant to other treatments in frozen embryo transfer (FET) cycles.

STUDY DESIGN

This is a hospital-based prospective study.

PATIENTS

Thirty-five women with persistent thin endometrium (<7 mm) resistant to standard treatments were involved in this study.

INTERVENTIONS

Intrauterine infusion of GCSF (300 mcg/1 ml) was done in patients with thin endometrium on day 14 of FET cycles, and their endometrial thicknesses were measured after 48 h of infusion.

MAIN OUTCOME MEASURES

The primary outcome was an increase in endometrial thickness and the secondary outcome measures were chemical and clinical pregnancies.

RESULTS

The endometrial thickness increased from 5.86 ± 0.58 to 6.58 ± 0.84 mm after GCSF infusion. In 19 of the 35 participants (54.28 %) endometrial thickness increased to ≥7 mm and they subsequently underwent embryo transfer. Of these, 3 (15.78 %) patients had chemical pregnancy, but there was no clinical pregnancy. In 16 participants, embryo transfer was canceled in view of insufficient endometrial thickness (<7 mm).

CONCLUSION

GCSF caused a small increase in endometrial thickness in women with persistent thin endometrium, but there was no improvement in their pregnancy rates.

Granulocyte colony-stimulating factor and reproductive medicine: A review

BACKGROUND

Recently, the use of granulocyte colony-stimulating factor (G-CSF) has been proposed to improve pregnancy outcomes in reproductive medicine.

OBJECTIVE

A systematic review of the current use of G-CSF in patients who have difficulty conceiving and maintaining pregnancy was performed.

MATERIALS AND METHODS

Two electronic databases (PubMed/ Medline and Scopus) were searched. Study selection, data extraction and quality assessment were performed in duplicate. The subject codes used were granulocyte colony-stimulating factor, G-CSF, recurrent miscarriage, IVF failure, and endometrium.

RESULTS

The search of electronic databases resulted in 215 citations (PubMed/ Medline: 139 and Scopus: 76), of which 38 were present in both databases. Of the remaining 177 publications, seven studies were included in the present review.

CONCLUSION

Treatment with G-CSF is a novel proposal for immune therapy in patients with recurrent miscarriage and implantation failure following cycles of IVF. However, a larger number of well-designed studies are required for this treatment to be established.

Effects of ulipristal acetate on human embryo attachment and endometrial cell gene expression in an in vitro co-culture system

STUDY QUESTION

Does ulipristal acetate (UPA) used for emergency contraception (EC) interfere with the human embryo implantation process?

SUMMARY ANSWER

UPA, at the dosage used for EC, does not affect human embryo implantation process, in vitro.

WHAT IS KNOWN ALREADY

A single pre-ovulatory dose of UPA (30 mg) acts by delaying or inhibiting ovulation and is recommended as first choice among emergency contraceptive pills due to its efficacy. The compound has also been demonstrated to have a dose-dependent effect on the endometrium, which theoretically could impair endometrial receptivity but its direct action on human embryo implantation has not yet been studied.

STUDY DESIGN, SIZE, DURATION

Effect of UPA on embryo implantation process was studied in an in vitro endometrial construct. Human embryos were randomly added to the cultures and cultured for 5 more days with UPA (n = 10) or with vehicle alone (n = 10) to record the attachment of embryos.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial biopsies were obtained from healthy, fertile women on cycle day LH+4 and stromal and epithelial cells were isolated. A three-dimensional in vitro endometrial co-culture system was constructed by mixing stromal cells with collagen covered with a layer of epithelial cells and cultured in progesterone containing medium until confluence. The treatment group received 200 ng/ml of UPA. Healthy, viable human embryos were placed on both control and treatment cultures. Five days later the cultures were tested for the attachment of embryos and the 3D endometrial constructs were analysed for endometrial receptivity markers by real-time PCR.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no significant difference in the embryo attachment rate between the UPA treated group and the control group as 5 out of 10 human embryos exposed to UPA and 7 out of 10 embryos in the control group attached to the endometrial cell surface (P = 0.650). Out of 17 known receptivity genes studied here, only 2 genes, HBEGF (P = 0.009) and IL6 (P = 0.025) had a significant up-regulation and 4 genes, namely HAND2 (P = 0.003), OPN (P = 0.003), CALCR (P = 0.016) and FGF2 (P = 0.023) were down-regulated with the exposure of UPA, compared with control group.

LIMITATIONS, REASONS FOR CAUTION

This proof of concept study was conducted with a few human embryos, as their availability was limited. Although the 3D model used for this study is well established and the artificial endometrial luminal epithelium shown to express progesterone regulated markers of endometrial receptivity it is still an in vitro model, lacking all cell types that constitute the receptive endometrium in vivo.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides new insights on the mechanism of action of UPA on human embryo implantation, demonstrating that UPA in a dosage used for EC does not affect embryo viability and the implantation process of embryo. Progesterone receptor modulators (PRMs) hold the potential to be attractive estrogen- and gestagen-free contraceptives and thus may be made available to a larger proportion of women globally due to these findings.

STUDY FUNDING/COMPETING INTERESTS

Swedish Research Council (K2010-54X-14212-09-3) and support provided through the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska University Hospital.

Colony Stimulating Factors 1, 2, 3 and early pregnancy steps: from bench to bedside

Reproductive immunology applies general immunology principles to specialised targets, reproduction and development. The involvement of colony-stimulating factors (CSFs) in reproduction illustrates this. The CSF family includes CSF-1 or macrophage CSF (M-CSF), CSF-2 or granulocyte macrophage CSF (GM-CSF), and CSF-3 or granulocyte CSF (G-CSF). Each member has a specific localisation and timed expression in the reproductive tract with specific functions involving them in ovulation, embryo implantation, placentation and further embryonic development. They are used in reproductive medicine, either as biomarkers of oocyte quality and competence (follicular G-CSF), or to supplement embryo culture media with human recombinant GM-CSF, or they are used as an innovative therapy by using human recombinant G-CSF for infertile patients. Given fundamental considerations on CSFs and their strong implication in reproduction, this review aimed to detail the current knowledge for each member of the family to improve our understanding of their implication in the maternal-foetal cytokinic dialogue and in possibly preventing reproductive disorders.

Granulocyte-Colony Stimulating Factor related pathways tested on an endometrial ex-vivo model

INTRODUCTION

Recombinant human Granulocyte-Colony Stimulating Factor (rhG-CSF) supplementation seems to be a promising innovative therapy in reproductive medicine, used in case of recurrent miscarriage, embryo implantation failure or thin endometrium, although its mechanisms of action remain unknown. Our aim was to identify possible endometrial pathways influenced by rhG-CSF.

MATERIALS AND METHODS

Hypothetical molecular interactions regulated by G-CSF were designed through a previous large scale endometrial microarray study. The variation of endometrial expression of selected target genes was confirmed in control and infertile patients. G-CSF supplementation influence on these targets was tested on an endometrial ex-vivo culture. Middle luteal phase endometrial biopsies were cultured on collagen sponge with or without rhG-CSF supplementation during 3 consecutive days. Variations of endometrial mRNA expression for the selected targets were studied by RT-PCR.

RESULTS

At the highest dose of rhG-CSF stimulation, the mRNA expression of these selected target genes was significantly increased if compared with their expression without addition of rhG-CSF. The selected targets were G-CSF Receptor (G-CSFR), Integrin alpha-V/beta-3 (ITGB3) implicated in cell migration and embryo implantation, Plasminogen Activator Urokinase Receptor (PLAUR) described as interacting with integrins and implicated in cell migration, Thymidine Phosphorylase (TYMP) implicated in local angiogenesis, CD40 and its ligand CD40L involved in cell proliferation control.

CONCLUSION

RhG-CSF seems able to influence endometrial expressions crucial for implantation process involving endometrial vascular remodelling, local immune modulation and cellular adhesion pathways. These variations observed in an ex-vivo model should be tested in-vivo. The strict indications or counter indication of rhG-CSF supplementation in reproductive field are not yet established, while the safety of its administration in early pregnancy on early embryogenesis still needs to be demonstrated. Nevertheless, rhG-CSF appears as a promising therapy in some difficult and unsolved cases of reproductive failure. Indications of pre-conceptual rhG-CSF supplementation may derive from a diagnosed lack of endometrial expression of some target genes.

Transvaginal perfusion of G-CSF for infertile women with thin endometrium in frozen ET program: A non-randomized clinical trial

BACKGROUND

We often see patients with a thin endometrium in ART cycles, in spite of standard and adjuvant treatments. Improving endometrial growth in patients with a thin endometrium is very difficult. Without adequate endometrial thickness these patients, likely, would not have reached embryo transfer.

OBJECTIVE

We planned this study to investigate the efficacy of intrauterine granulocyte colony-stimulating factor (G-CSF) perfusion in improving endometrium, and possibly pregnancy rates in frozen-thawed embryo transfer cycles.

MATERIALS AND METHODS

This is a non-randomized intervention clinical trial. Among 68 infertile patients with thin endometrium (-7 mm) at the 12(th)-13(th) cycle day, 34 patients received G-CSF. G-CSF (300 microgram/1mL) to improve endometrial thickness was direct administered by slow intrauterine infusion using IUI catheter. If the endometrium had not reached at least a 7-mm within 48-72 h, a second infusion was given. Endometrial thickness was assessed by serial vaginal ultrasound at the most expanded area of the endometrial stripe.

RESULTS

The cycle was cancelled in the patients with thin endometrium (endometrial thickness below 7mm) until 19(th) cycle day ultimately The cycle cancelation rate owing to thin endometrium was similar in G-CSF group (15.20%), followed by (15.20%) in the control group (p=1.00). The endometrial growth was not different within 2 groups, an improvement was shown between controlled and G-CSF cotreated groups, with chemical (39.30% vs. 14.30%) and clinical pregnancy rates (32.10% vs. 12.00%) although were not significant.

CONCLUSION

Our study fails to demonstrate that G-CSF has the potential to improve endometrial thickness but has the potential to improve chemical and clinical pregnancy rate of the infertile women with thin endometrium in frozen-thawed embryo transfer cycle.