Chronic endometritis: Really so relevant in repeated IVF failure?

Understanding the Role of Female Genital Tract Microbiome in Recurrent Implantation Failure

The realization of the role of the microbiome of the female reproductive tract in health and disease has opened numerous possibilities for the scientific examination of the intertwining role between the human host and its microbiota. The imbalance in the composition of the microbial communities of the vagina and uterus is now recognized as a risk factor for many complications in pregnancy and according to the data from numerous studies, it is possible for this imbalance to play a crucial role in creating a hostile endometrial environment, and therefore, contributing to the etiology of recurrent implantation failure. Nevertheless, our current understanding of these complicated biological phenomena is far from complete, and in the future, there needs to be a systematic and thorough investigation of the diagnosis and therapy of this condition. This will enable scientists who engage in the field of assisted reproduction technologies to accurately identify and cure women in whom dysbiosis hinders the achievement of a healthy pregnancy.

The timing for embryo transfer after antibiotic therapy for chronic endometritis

OBJECTIVE

To explore the optimal timing of embryo transfer after the first round treatment of chronic endometritis (CE) in vitro.

MATERIALS AND METHODS

A total of 184 patients were recruited from a retrospective analysis of a large university-affiliated reproduction center in 2021. Some people chose to undergo embryo transfer in the same menstrual cycle with the first round of antibiotic treatment (Group 1, n = 29). Others received embryo transfer in the next cycle after the first round of treatment (Group 2, n = 69) or even one cycle later (Group 3，n = 96).

RESULTS

Patients in Group 1 got significantly lower biochemical pregnancy rate and clinical pregnancy rate and live birth rate than Group 2 (p < 0.05) and also Group 3 (p < 0.05). Then after comparing the influence factors, we found embryo transfer in the next cycle after antibiotic treatment had a higher clinical pregnancy rate than group 1 (OR = 3.2 p < 0.05) and group 3(OR = 2.5, p < 0.05). The live birth rate in group 2 was higher than group 1(OR = 3.5, p < 0.05).

CONCLUSION

These findings illustrate that embryo transfer in the next menstrual cycle is the optimal time. Embryo transfer in the same menstrual cycle with the first round of treatment reduces the pregnancy rate.

Platelet rich plasma alleviates endometritis induced by lipopolysaccharide in mice via inhibiting TLR4/NF-κB signaling pathway

BACKGROUND

Endometritis is an inflammatory reaction of the lining of uterus, leading to the occurrence of infertility. Platelet rich plasma (PRP) has been proven to exhibit extremely effective for the treatment of endometrium-associated infertility, but the mechanism of its prevention for endometritis remains unclear.

OBJECTIVE

The present study aimed to investigate the protective effect of PRP against endometritis induced by lipopolysaccharide (LPS) and elucidate the mechanism underlying these effects.

METHODS

Mouse model of endometritis was established by intrauterine perfusion of LPS. PRP intrauterine infusion was administered at 24 h after LPS induction. After another 24 h, the uterine tissues were harvested to observe histopathological changes, production of proinflammatory cytokines, variation of the Toll-like receptor 4/nuclear factor κB (TLR4/NF-κB) signaling pathways, and validated the anti-inflammatory effect of PRP. The myeloperoxidase (MPO) activity and concentration of nitric oxide (NO) were determined using assay kit. Proinflammatory chemokines (tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6)) were measured by ELISA and Real-Time PCR. The activity of TLR4/NF-κB pathway in uterine tissues was measured by Western blotting.

RESULTS

Hematoxylin-eosin staining (H&E) appeared that PRP remarkably relieved the impairment of uterine tissues. Detection of MPO activity and concentration of NO revealed that PRP treatment distinctly mitigated infiltration of inflammatory cells in mice with endometritis induced by LPS. PRP treatment significantly affected the expression of TNF-α, IL-1β, and IL-6. PRP was also found to suppress LPS-induced activation of TLR4/NF-κB pathway.

CONCLUSION

PRP effectively alleviates LPS-induced endometritis via restraining the signal pathway of TLR4/NF-κB. These findings provide a solid foundation for PRP as a potential therapeutic agent for endometritis.

Hysteroscopic features suggestive of chronic endometritis: a systematic review

The purpose of this systematic review is to identify common hysteroscopic findings suggestive of endometritis, chronic or subclinical, based on current scientific evidence. Data sources were MEDLINE, Embase, PubMed and other sources of grey literature. Four (4) authors independently selected studies addressing hysteroscopic detection of CE based on specific and clearly stated hysteroscopic criteria. The diagnosis was confirmed by histologic assessment, as stated in the materials and methods of these studies included. The initial search identified 599 studies, of which 21 met the inclusion criteria. Significant heterogeneity among published studies on Chronic endometritis (CE) remains the main limitation in performing a metanalysis and further analysis of diagnostic accuracy on the subject. Hysteroscopy is an important diagnostic tool in cases of chronic endometritis when accompanied by endometrial biopsies. Clinicians relate hyperaemia and endometrial oedema with chronic endometritis while more than half include micropolyposis as a pathognomonic feature of this subclinical condition. Micropolyps, stromal oedema, haemorrhagic spots, strawberry aspect, and hyperaemia are proposed as adequate indicators of hysteroscopic evidence of CE according to the literature. The impact of CE in long-term reproductive outcomes remain unclear, thus clinicians ought to communicate this to the patients and provide treatment where clinically appropriate. In addition, we present hysteroscopic images of histologically confirmed CE cases that could play the role of a hysteroscopic atlas.

Pregnancy by Oocyte Donation: Reviewing Fetal-Maternal Risks and Complications

Oocyte donation (OD) has greatly improved over the last three decades, becoming a preferred practice of assisted reproductive technology (ART) for infertile women wishing for motherhood. Through OD, indeed, it has become possible to overcome the physiological limitation due to the ovarian reserve (OR) exhaustion as well as the poor gamete reliability which parallels the increasing age of women. However, despite the great scientific contribution related to the success of OD in the field of infertility, this practice seems to be associated with a higher rate of major risky events during pregnancy as recurrent miscarriage, infections and placental diseases including gestational hypertension, pre-eclampsia and post-partum hemorrhage, as well as several maternal-fetal complications due to gametes manipulation and immune system interaction. Here, we will revisit this questioned topic since a number of studies in the medical literature focus on the successful aspects of the OD procedure in terms of pregnancy rate without, however, neglecting the risks and complications potentially linked to external manipulation or heterologous implantation.

Effect of different antibiotic therapies on the reproductive outcomes of fresh embryo transfer for chronic endometritis: A retrospective cohort study

OBJECTIVE

To investigate the reproductive outcomes by comparing two kinds of antibiotic schemes for chronic endometritis (CE) in infertile women's fresh embryo transfer (FET) cycles and identify subgroups of patients with CE who need long-term antibiotics treatment.

DESIGN

A retrospective cohort study.

SETTING

University-based reproductive medical center.

PATIENT(S)

A total of 492 women with CD138-positive plasmacytes per 10 high-power fields (CD138+/10HPF).

INTERVENTION(S)

Hysteroscopy was performed and endometrial biopsy samples were collected in the proliferative phase. Long-term or short-term antibiotics were administrated. After antibiotics treatment, patients underwent in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) and received ET.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate, clinical pregnancy rate, clinical miscarriage rate.

RESULT (S)

There were no significant differences in pregnancy outcomes between patients with CD138+/10HPF 1-4 (low-grade CE) who received long-term antibiotic therapy and short-term antibiotics groups. Among women with CD138+/10HPF ≥5 (high-grade CE), live birth rate (48.4% vs. 14.7%, p = .001), clinical pregnancy rate (66.7% vs. 35.3%, p = .002) and ongoing pregnancy rate (59.1% vs. 20.6%, p < .001) in the long-term arm were significantly higher than that in the short-term arm. The clinical miscarriage rate (21.0% vs. 58.3%, p = .013) was statistically lower in the long-term antibiotics group, but no statistical differences were found between the two groups in preterm delivery rate.

CONCLUSION

Long-term antibiotics treatment was a sensible choice to improve pregnancy outcomes in women with CD138+/10HPF ≥5 (high-grade CE). The pregnancy outcomes of women with low-grade CE only defined by histological diagnosis were not greatly improved after antibiotic therapy. Therefore, we recommended the proper diagnosis criteria were CD138+/10HPF ≥5 pathologically.

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.

Association between Endometrial Polyps and Chronic Endometritis: Is It Time for a Paradigm Shift in the Pathophysiology of Endometrial Polyps in Pre-Menopausal Women? Results of a Systematic Review and Meta-Analysis

BACKGROUND

Chronic endometritis (CE) and endometrial polyps (EPs) are common conditions in reproductive age women. CE is an infectious disorder of the endometrium characterized by signs of chronic inflammation at hysteroscopic and histological analyses. EPs are abnormal endometrial growths containing glands, stroma and blood vessels projecting from the lining of the uterus. During the last years, different authors have investigated the correlation between CE and EPs, with controversial results. The aim of this study was to summarize available evidence on the potential correlation between CE and EPs.

DESIGN

Systematic literature review and meta-analysis.

METHODS

Observational-studies were identified by searching electronic databases from their inception to September 2021. Only studies on pre-menopausal women were included. Statistical analysis was performed using MedCalc 16.4.3 (Ostend, Belgium) and Review Manager version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration). The summary measures were reported as pooled proportion or odds ratio (OR) with 95% confidence interval (CI). The primary outcome was to evaluate the prevalence of CE in women with EPs. The secondary outcome was to determine the prevalence of CD-138-positive EPs among EPs. Tertiary outcomes were to compare the prevalence of CE in women with EPs versus women with a non-polypoid endometrium and to compare the prevalence of CE in women with a single EP versus women with multiple EPs.

RESULTS

Eight observational studies (n = 3225 patients) were included in quantitative synthesis. Pooled prevalence of CE among women with EPs was 51.35% (95% CI, 27.24-75.13%). Pooled proportion of CD-138-positive EPs among EPs was 70.73% (95% CI, 55.73-83.68%). Women with EPs showed higher prevalence of CE compared to women without EPs (OR 3.07, 95% CI 1.59-5.95). Women with ≥3 EPs had higher prevalence of CE then women with a single EP (OR 3.43, 95% CI 1.83-6.46).

CONCLUSIONS

In pre-menopausal women, CE and EPs may have a dependent relationship and may represent two consequent steps of a common pathological process.

Sildenafil Supplementation for Women Undergoing Infertility Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of this systematic review and meta-analysis is to summarize data on the effectiveness of Sildenafil supplementation for women undergoing assisted reproduction techniques. This meta-analysis of randomized controlled trials (RCTs) evaluates the effects of Sildenafil administration during infertility treatments compared with a control group in infertile women. Outcomes evaluated were endometrial thickness (ETh) and the clinical pregnancy rate (CPR). The chemical pregnancy rate (ChPR) was also evaluated. Pooled results were expressed as the risk ratio (RR) or mean differences (MD) with a 95% confidence interval (95% CI). Women undergoing ovulation induction who received Sildenafil showed higher ETh and a higher CPR in comparison to controls. In this group, both the ETh and ChPR resulted in significantly higher values only with delayed start administration. Women undergoing fresh or frozen embryo transfer who received Sildenafil showed no significant advantages regarding ETh and CPR in comparison to controls. In this group, we found a significantly higher ChPR in women receiving Sildenafil. A subgroup analysis revealed significant advantages regarding ETh with oral administration for women undergoing fresh or frozen embryo transfer. Sildenafil therapy appears to improve endometrial thickness and pregnancy rate in women undergoing timed intercourses but it resulted not effective in IUI and IVF treatments. Further RCTs with rigorous methodology are still mandatory.

Introducing intrauterine antibiotic infusion as a novel approach in effectively treating chronic endometritis and restoring reproductive dynamics: a randomized pilot study

The chronic nature of Chronic Endometritis (CE) along with the challenging management and infertility entailed, call for cutting-edge therapeutic approaches. This study introduces the novel treatment of intrauterine antibiotic infusion (IAI) combined with oral antibiotic administration (OAA), and it assesses respective performance against the gold standard treatment of OAA. Data sourced herein reports on treatment efficiency and fertility restoration for both patients aiming to conceive naturally or via In Vitro fertilization. Eighty CE patients, 40 presenting with recurrent implantation failure, and 40 with recurrent pregnancy loss, were enrolled in the IVF and the natural conception arm respectively. Treatment was subjected to randomization. Effectively treated patients proceeded with either a single IVF cycle or were invited to conceive naturally over a 6-month period. Combination of IAI and OAA provided a statistically significant enhanced effectiveness treatment rate (RR 1.40; 95%CI 1.07–1.82; p = 0.01). No statistically significant difference was observed regarding the side-effects rate (RR 1.33; 95%CI 0.80–2.22; p = 0.52). No statistically significant difference was observed for either arm regarding live-birth rate. Following an intention-to-treat analysis, employment of IAI corresponds to improved clinical pregnancy rate-albeit not reaching statistical significance. In conclusion, complimentary implementation of IAI could provide a statistically significant enhanced clinical treatment outcome.

Treatment following hysteroscopy and endometrial diagnostic biopsy increases the chance for live birth in women with chronic endometritis

Problem

Repeated implantation failure and recurrent pregnancy loss are associated with chronic endometritis, a persistent endometrial inflammation. Its diagnosis and treatment may increase pregnancy and live birth rates. The aim of this study was to assess the effectiveness of endometrial diagnostic biopsy and subsequent antibiotic treatment in cases of chronic endometritis on reproductive outcomes over a long observation period.

Method of Study

We conducted a historical cohort study (2014–2018) at our University‐based infertility center that included women (n = 108) with repeated implantation failure or recurrent pregnancy loss without known pathologies associated with either condition. Forty‐one women underwent a hysteroscopy only (reference group); the remaining 67 women underwent, in addition to the hysteroscopy, an endometrial diagnostic biopsy with immunohistochemically staining for CD138 to detect plasma cells (biopsy group). If one or more plasma cells were detected, the women were treated with doxycycline 100 mg twice a day orally for 2 weeks. We performed stratified survival analysis (Kaplan‐Meier) and Cox regression.

Results

The biopsy group had higher chances of pregnancy (hazard ratio 2.28; 95% confidence interval 1.23–4.24; p = .009) and of live birth (hazard ratio 2.76; 95% confidence interval 1.30–5.87; p = .008) compared with the reference group. In the sensitivity analysis, repeated implantation failure or recurrent pregnancy loss did not affect the outcome.

Conclusion

Endometrial diagnostic biopsy followed by antibiotic treatment in case of chronic endometritis in women with repeated implantation failure or recurrent pregnancy loss may increase the chances for live birth.

Antibiotic therapy versus no treatment for chronic endometritis: a case-control study

OBJECTIVE

To demonstrate the infectious nature of chronic endometritis (CE) in an inductive way by comparing the results of germ-oriented antibiotic therapy vs. no treatment in women with CE.

DESIGN

Retrospective, nonconcurrent case-control study.

SETTING

Tertiary hysteroscopic center in a university teaching hospital.

PATIENT(S)

Sixty-four consecutive women with CE who received antibiotic therapy (Group A) compared with a historical group of 64 patients with CE who refused antibiotic therapy (Group B).

INTERVENTIONS(S)

CE was diagnosed through hysteroscopy, histology, and immunohistochemistry for CD138. Patients in both groups were tested for CE twice to evaluate the cure rate after antibiotic therapy (Group A) or no treatment (Group B). For patients with persistent disease, antibiotic therapy was repeated up to 3 times. Antibiotics were chosen based on endometrial culture (with antibiogram).

MAIN OUTCOME MEASURE(S)

The primary outcome was to compare the cumulative cure rate of CE (defined as the percentage of patients without CE at the test of cure) between groups.

RESULT(S)

Among Group A, 20 patients (31.25%) experienced CE resolution after 1 antibiotic cycle, an additional 20 patients (31.25%) after 2 antibiotic cycles, and 12 patients (19.35%) after 3 antibiotic cycles. In 12 cases (18.75%), CE was persistent after 3 cycles of antibiotics. The cure rate of CE in Group A after 1 cycle of antibiotics was significantly higher than that of Group B (32.25% vs. 6%). Similarly, the cumulative cure rate was considerably higher in Group A vs. Group B (81.3% vs. 6%). Notably, the number of positive cases decreased significantly with all techniques between the first and second evaluation, whereas at the third evaluation, there was a statistical decrease only with hysteroscopy and CD138⁺ cell count but not with histology. The cumulative number of cases of CE diagnosed at hysteroscopy was significantly higher than histology and immunohistochemistry.

CONCLUSION(S)

Our study demonstrated the superiority of antibiotic therapy compared with no treatment for CE cure. Accordingly, the infectious nature of CE is inferred.

Chronic endometritis and altered embryo implantation: a unified pathophysiological theory from a literature systematic review

PURPOSE

Chronic endometritis (CE) is a frequent hysteroscopic and histological finding which affects embryo transfer implantation during IVF-ICSI cycles. In particular, CE impairs proper decidualization and, subsequently, implantation. Although this correlation has been clearly clarified, a pathophysiological explanation assembling all the studies performed has not been elucidated yet. For this reason, we have structured a systematic review considering all the original articles that evaluated a pathological element involved in CE and implantation impairment.

METHODS

The authors searched electronic databases and, after screening, collected 15 original articles. These were fully scanned and used to create a summary pathway.

RESULTS

CE is primarily caused by infections, which lead to a specific cytokine and leukocyte pattern in order to prepare the uterus to fight the noxa. In particular, the immunosuppression requested for a proper semi-allogenic embryo transfer implantation is converted into an immunoreaction, which hampers correct embryo implantation. Moreover, endometrial vascularization is affected and both irregular vessel density and luminal thickening and thrombosis reduce what we have first identified as endometrial flow reserve. Finally, incorrect uterine wave propagation could affect embryo contact with decidua.

CONCLUSION

This is the first summary of evidence on CE pathophysiology and its relationship with infertility. Understanding the CE pathophysiology could improve our knowledge in embryo transfer success.

Endometrial CD138 count appears to be a negative prognostic indicator for patients who have experienced previous embryo transfer failure

OBJECTIVE

To explore the predictive value of endometrial CD138 expression in the natural cycle preceding frozen embryo transfer in patients with normal endometrial dating and histopathologic features, who previously failed the transfer of two high-quality fresh embryos.

DESIGN

Retrospective analysis.

SETTING

University-affiliated hospital.

PATIENT(S)

Women with normal endometrial dating and histopathologic features who previously failed the transfer of two high-quality fresh embryos, and who then underwent an endometrial scratching operation preceding a natural cycle.

INTERVENTION(S)

Paraffin-embedded endometrial samples cut into sections for immunohistochemistry staining of CD138 (syndecan-1) expression, then clinical information for these patients reviewed and analyzed.

MAIN OUTCOME MEASURE(S)

Clinical rates of pregnancy and implantation.

RESULT(S)

A total of 141 women met the inclusion criteria. Of these patients, about 31.2% (44 of 141) were positive for CD138 expression, with CD138 counts ranging from 0 to 33. Receiver operating characteristic (ROC) curves were analyzed to determine whether the number of cells expressing CD138 (CD138⁺ cells) predicted a successful pregnancy. The areas under the ROC curves based on CD138⁺ cell density and CD138⁺ cell count were 0.660 and 0.658, respectively. The clinical pregnancy and embryo implantation rates in patients not expressing CD138 (80.04% and 64.9%, respectively) were statistically significantly higher than rates in CD138⁺ patients (52.7% and 46.8%, respectively). In addition, the higher the number of cells expressing CD138, the worse the outcome of the pregnancy. Finally, clinical data showed that free pelvic fluid on the day of endometrial sampling (identified using transvaginal ultrasound) might be a risk factor for CD138 expression.

CONCLUSION(S)

Endometrial CD138⁺ count might be a valuable marker predicting pregnancy outcomes after frozen embryo transfer in patients with normal endometrial dating and histopathologic features who previously failed the transfer of two high-quality fresh embryos.

Unified diagnostic criteria for chronic endometritis at fluid hysteroscopy: proposal and reliability evaluation through an international randomized-controlled observer study

OBJECTIVE

To develop a consensus on the diagnostic criteria for chronic endometritis (CE) at hysteroscopy (HSC), and to evaluate these proposed criteria in a randomized-controlled observer study.

DESIGN

Systematic review of studies evaluating the diagnostic accuracy of HSC in CE diagnosis; Delphi consensus on hysteroscopic diagnostic criteria for CE; randomized-controlled observer study to evaluate the reproducibility of the proposed diagnostic criteria.

SETTING

Not applicable.

PARTICIPANT(S)

Experts from different countries were involved in the systematic review and contributed to the Delphi consensus. Physicians from different countries were involved in the observer study.

INTERVENTION(S)

After reaching consensus on the diagnostic criteria, the Delphi poll created a questionnaire including 100 hysteroscopic pictures (50 from women with CE [domain 1] and 50 from women without CE [domain 2]), with a single question per picture (Answer_A: suggestive of CE; answer B: not suggestive of CE). A total of 200 physicians were invited to take part in the observer study. Before completing the questionnaire, physicians were randomized to receive a description of the diagnostic criteria (group A) or no such information (group B).

MAIN OUTCOME MEASURE(S)

The primary outcome was to compare the questionnaire scores for the two groups of observers. The secondary outcome was to assess the interobserver agreement in the diagnosis of CE in each group.

RESULT(S)

A total of 126 physicians completed the questionnaire (62 in group A and 64 in group B). Observers in group A obtained higher total scores compared with those in group B (P<.001). Specifically, group A showed higher mean score in domain 1 (P<.001), but not in domain 2 (P=.975). A substantial agreement was found among observers in group A (intraclass correlation coefficient [ICC] 0.78), whereas a fair agreement was found among observers in group B (ICC 0.40).

CONCLUSION(S)

This randomized-controlled observer study found a positive impact of our criteria on physicians' ability to recognize CE.

Endometrial scratching for infertile women undergoing a first embryo transfer: a systematic review and meta-analysis of published and unpublished data from randomized controlled trials

OBJECTIVE

To investigate endometrial scratch injury (ESI) as an intervention to improve IVF outcome in women undergoing a first ET.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertile women undergoing a first fresh/frozen embryo transfer.

INTERVENTION(S)

We included published and unpublished data from randomized controlled trials in which the intervention group received ESI and controls received placebo or no intervention. Pooled results were expressed as relative risk (RR) with 95% confidence interval (CI). The review protocol was registered in PROSPERO to start the data extraction (CRD42018087786).

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy/live birth rate (OPR/LBR), clinical pregnancy rate (CPR), multiple pregnancy rate (MPR), miscarriage rate (MR), and ectopic pregnancy rate (EPR).

RESULT(S)

Seven studies were included (1,354 participants). We found a nonsignificant difference between groups in terms of OPR/LBR, CPR, MR, MPR, and EPR. Subgroup analysis found that ESI on the day of oocyte retrieval (achieved by a Novak curette) reduced OPR/LBR (RR 0.31, 95% CI 0.14-0.69) and CPR (RR 0.36, 95% CI 0.18-0.71), whereas ESI during the cycle preceding ET (performed through soft devices) had no effect on OPR/LBR and CPR. No difference in the impact of ESI was observed between fresh and frozen embryo transfer.

CONCLUSION(S)

Current evidence does not support performing ESI with the purpose of improving the success of a first ET attempt.