Obstetric and perinatal outcome of the women with repeated implantation failures or recurrent pregnancy losses who received pre- and post-conception tacrolimus treatment

Tacrolimus treatment in women with repeated implantation failures

Background

Tacrolimus is an immunosuppressive drug that works as a calcineurin inhibitor to improve the reproductive outcomes for women who have experienced multiple implantation failures (RIF) and show elevated type 1 helper T (Th1)/Th2 cell ratios.

Methods

In the first part of this review, we indicate how we re-evaluated the cut-off index for selecting the participants in a tacrolimus regimen via transferred euploid blastocysts. In the second part, we cite cases where tacrolimus has improved the live birth rate for women who have experienced recurrent pregnancy losses (PRL) and we introduce the utility of tacrolimus treatment to prevent obstetrical complications.

Main Findings

After reconsideration of the cut-off index (Th1/Th2 ≥ 11.8), however, the pregnancy rates of women with tacrolimus were significantly higher than those of women without tacrolimus. The PRL women treated with tacrolimus showed significantly lower rates of biochemical pregnancy, but higher live-birth rates compared with women who were not treated with tacrolimus. Moreover, prior severe obstetrical complications could be controlled via the administration of tacrolimus during pregnancy.

Conclusion

Tacrolimus has become indispensable in the field of solid-organ transplantation, and in the near future, it should become an essential agent in the reproductive field, as well.

Co-administration of tacrolimus and low molecular weight heparin in patients with a history of implantation failure and elevated peripheral blood natural killer cell proportion

AIM

To investigate the therapeutic effect of co-administration of tacrolimus (TAC) and low-molecular-weight heparin (LMWH) or LMWH only on pregnancy outcomes in the female with a history of implantation failure and elevated peripheral blood natural killer (pNK) cell proportion in frozen-thawed embryo transfer cycles.

METHODS

To evaluate the pregnancy parameters for 249 patients with ≥2 implantation failures and pNK cell proportion ≥12% by analyzing a retrospective observational cohort study. Sixty patients had received the co-administration TAC and LMWH (TAC & LMWH group), 85 others had only taken LMWH (LWMH group), and the rest did not take any particular drugs (control group).

RESULTS

The experimental finding indicated that the TAC & LMWH group and the LMWH group showed higher clinical pregnancy rates than the control group (p < 0.05), and TAC & LMWH group had a much higher live birth rate. According to the binary logistic regression analysis, the combination of TAC and LMWH was conducive to clinical pregnancy and live birth rate and reduced the possibility of miscarriage. It would not affect the result of spontaneous abortion and live birth, although the LMWH was only beneficial to clinical pregnancy. In addition, these findings were similar for these three groups' obstetrical and neonatal outcomes.

CONCLUSIONS

The combination of TAC and LMWH can improve clinical pregnancy and live birth rates and reduce the risk of spontaneous miscarriage in patients with a history of implantation failure and elevated pNK ratio. LMWH is also beneficial to clinical pregnancy.

Unexplained recurrent pregnancy loss: Novel causes and advanced treatment

In this study, recent research focusing on recurrent pregnancy loss (RPL) are reviewed. Recurrent pregnancy loss is a devastating reproductive health burden that affects about 5% of couples trying to conceive globally. Currently, there are few evidence-based diagnostic and treatment strategies for RPL. More so, the number of unexplained etiology cases in patients with RPL arrives at 50%. Here, we discuss the progress in diagnosis and treatment of unexplained RPL, as well as recommended treatment strategies and controversial etiologies.

Research trends and hotspots of recurrent pregnancy loss with thrombophilia: a bibliometric analysis

BACKGROUND

Thrombophilia is a group of disorders that result in a blood hypercoagulable state and induce thrombosis, which was found widely existed in recurrent pregnancy loss (RPL). More and more research about thrombophilia has been conducted but the association between thrombophilia and RPL remains uncertain. Thus, it's necessary to combine relevant literature to find the research hotspots and analyze the internal link between different study points, and then predict the development trend in RPL with thrombophilia.

METHODS

Relevant articles between 1970 and 2022 were obtained from the Web of Science (WoS) database. Software VOSviewer and CiteSpace were used to perform the analysis and conduct visualization of scientific productivity and emerging trends.

RESULTS

Seven hundred twenty-five articles published in recent 30 years by 3205 authors from 1139 organizations and 68 countries were analyzed. 37authors, 38 countries, and 53 organizations published papers ≥5. The United States was the most productive country and Univ Amsterdam was the most productive institution. Journal thrombosis and haemostasis had the most total citations. In keyword and clusters, factor-v-Leiden, inherited thrombophilia, activated protein-c, low-dose aspirin, molecular-weigh heparin, polymorphism had high-frequency focus on its etiology, diagnostics, and therapeutics. The strongest keyword bursts showed the research hotspots changed over time.

CONCLUSIONS

There could be differences in the clinical relevance of different type of thrombophilia, as well as single and multiple thrombophilic factors. Anticoagulation and immunotherapy are currently the main treatment options. More clinical trials and basic research are expected and we should attach more attention to the whole management of in-vitro fertilization in the future.

Improved pregnancy outcomes of cyclosporine A on patients with unexplained repeated implantation failure in IVF/ICSI cycles: A retrospective cohort study

PROBLEM

Repeated implantation failure (RIF) is a daunting obstacle restricting the further improvement of embryo implantation rate (IR) and live birth rate (LBR). The beneficial effect of cyclosporine A (CsA) on reproductive outcomes of unexplained RIF(URIF) was explored after de novo embryo transfer (ET).

METHOD OF STUDY

A retrospective cohort study was conducted, comparing pregnancy outcomes of 146 cycles (CsA group, n = 62; control group, n = 84) at the IVF center of Suzhou Municipal Hospital from April 2016 to March 2020.

RESULTS

Baseline and transfer cycle characteristics of participants were comparable between groups. Overall, CsA exerted obvious improvement on IR (51.16% vs 31.97%, P = .006), clinical pregnancy rate (CPR) (58.06% vs 38.10%, P = .017), and LBR (48.39% vs 32.14%, P = .047). Especially, CsA showed remarkably enhancement on IR (41.38% vs 14.63%, P = .012), CPR (47.62% vs 17.24%, P = .021) of non-high quality embryos. No difference in obstetric and pediatric complications was observed, and no birth defects were reported under CsA application. CsA was found to be a predictor of clinical pregnancy [fine adjusted OR 2.360, 95 % CI 1.165-4.781; P = .017] and live birth [fine adjusted OR 2.339, 95% CI 1.124-4.867; P = .023] for multivariate logistic regression. Not surprisingly, the number of high quality embryos should also be considered as an independent predictor for clinical pregnancy [fine adjusted OR 1.637,95%CI 1.027-2.609; P = .038] and live birth [fine adjusted OR 1.890, 95% CI 1.165-3.068; P = .010].

CONCLUSION

CsA application in patients with URIF promotes the pregnancy outcomes and does not increase the risk of obstetric and pediatric complications.

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.

Novel approaches to the management of recurrent pregnancy loss: The OPTIMUM (OPtimization of Thyroid function, Thrombophilia, Immunity, and Uterine Milieu) treatment strategy

PURPOSE

Does the OPtimization of Thyroid function, Thrombophilia, Immunity, and Uterine Milieu (OPTIMUM) treatment strategy, developed for treating repeated implantation failure (RIF), contribute to improving pregnancy outcomes in patients with a history of recurrent pregnancy loss (RPL)?

METHODS

Between 2018 and 2019, women with RPL after two or more clinical pregnancy losses underwent RPL testing. We treated chronic endometritis with antibiotics, high Th1/Th2 cell ratios with vitamin D and/or tacrolimus, overt/subclinical hypothyroidism with levothyroxine, and thrombophilia with low-dose aspirin. Of 168 consecutive women aged ≤43 years, 115 underwent RPL testing. We compared 100 pregnancies (90 women) and 46 pregnancies (41 women) with and without the OPTIMUM treatment strategy, respectively.

RESULTS

RPL testing identified intrauterine abnormalities in 66 (57.4%), elevated Th1/Th2 cell ratios in 50 (43.5%), thyroid dysfunction in 33 (28.7%), and thrombophilia in 33 (28.7%). The live birth rate in the OPTIMUM group was significantly higher than that in the control group among women aged <40 years (78.1% and 42.3%, respectively; p = 0.002), but no significant difference was observed in women aged ≥40 years (55.6% and 30.0%, respectively; p = 0.09).

CONCLUSIONS

The OPTIMUM treatment strategy improved pregnancy outcomes in patients with not only RIF but also RPL.

The Impact of New Immunological Therapeutic Strategies on Recurrent Miscarriage and Recurrent Implantation Failure

Maternal-fetal immune dysregulation is one of the risk factors that increases the probability of embryo rejection and reproductive failure. The stimulation of immunological tolerance and suppression of immunological rejection are prerequisites for protecting embryos and preventing immunological attacks. Hence, it appears that immunomodulatory and immunosuppressive therapies can manage reproductive failures by controlling immune cells. The current medical literature has shown that immunotherapy approaches and cell therapy have promising results in improving pregnancy outcomes and live birth rates. These outcomes are obtained by regulating maternal immune responses, and exerting positive effects on human reproductive processes.

Therapeutic Potentials of Low-Dose Tacrolimus for Aberrant Endometrial Features in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a major anovulatory infertility affecting a great proportion of women of childbearing age and is associated with obesity, insulin resistance and chronic inflammation. Poor endometrial receptivity and recurrent implantation failure are major hurdles to the establishment of pregnancy in women with PCOS. The accumulating body of evidence obtained from experimental and clinical studies suggests a link between inherent adaptive and innate immune irregularities and aberrant endometrial features in PCOS. The use of conventional therapeutic interventions such as lifestyle modification, metformin and ovarian stimulation has achieved limited clinical success in restoring ovulation and endometrial receptivity in women with PCOS. Unlike other immunosuppressive drugs prescribed in the clinical management of autoimmune and inflammatory disorders that may have deleterious effects on fertility and fetal development, preclinical studies in mice and in women without PCOS but with repeated implantation failure revealed potential therapeutic benefits for the use of low-dose tacrolimus in treating female infertility. Improved systemic and ovarian immune functions, endometrial progesterone receptor and coreceptor expressions and uterine vascular adaptation to pregnancy were among features of enhanced progesterone-receptor sensitivity in the low-dose tacrolimus-treated mouse model of the disease. In this review, we have compiled available experimental and clinical data in literature on endometrial progesterone resistance and current therapeutic options, as well as mechanisms of actions and reported outcomes relevant to the potential therapeutic benefits for the use of low-dose tacrolimus in treating PCOS-associated female infertility.

Analysis of the risk factors and treatment for repeated implantation failure: OPtimization of Thyroid function, IMmunity, and Uterine Milieu (OPTIMUM) treatment strategy

PROBLEM

What are the pregnancy outcomes after the OPtimization of Thyroid function, Immunity, and Uterine Milieu (OPTIMUM) treatment strategy in patients with repeated implantation failure (RIF)?

METHOD OF STUDY

Infertile women with a history of RIF after more than three embryo transfer (ET) cycles underwent implantation testing, including a hysteroscopy, endometrial biopsy for CD138 immunostaining and bacterial culture, and serum 25-hydroxyvitamin D₃ , interferon-γ-producing helper T (Th1) cell, IL-4-producing helper T (Th2) cell, thyroid-stimulating hormone, thyroid peroxidase antibody, and thrombophilia screening between April 2017 and August 2018. We treated chronic endometritis with antibiotics, aberrant high Th1/Th2 cell ratios with vitamin D and/or tacrolimus intake, overt/subclinical hypothyroidism with levothyroxine, and thrombophilia with low-dose aspirin. Of the 116 RIF women, 88 women with 133 ET cycles were recruited from a questionnaire-based survey regarding pregnancy outcomes. Fifty-nine consecutive RIF patients without the OPTIMUM treatment strategy were also recruited as a control.

RESULTS

The 116 women with RIF after the OPTIMUM treatment strategy were 38.3 ± 3.8 years old and had an implantation failure history over 5 (3-19) ET cycles. Implantation testing identified impaired intrauterine circumstances in 75 women (64.7%), an aberrant elevated Th1/Th2 cell ratio in 56 women (48.3%), and thyroid abnormalities in 33 women (28.4%). Cumulative ongoing pregnancy rates including spontaneous pregnancy in the patients aged < 40 and ≥ 40 years were 72.7% and 45.5% within two ET cycles, respectively. The pregnancy outcomes in the OPTIMUM group were significantly higher than those in the control.

CONCLUSIONS

The OPTIMUM treatment strategy improved pregnancy outcomes in patients with RIF.

The use of multiplex staining to measure the density and clustering of four endometrial immune cells around the implantation period in women with recurrent miscarriage: comparison with fertile controls

Serval studies showed an increased uterine natural killer cell density in women with recurrent miscarriage. However, no study has previously investigated the density and clustering of major immune cells simultaneously in precisely timed endometrial specimen section of this group of women. This study aimed to investigate the profile of endometrial immune cells populations and clustering level simultaneously in women with recurrent miscarriage and compare the results to fertile controls. A total of 30 women with unexplained recurrent miscarriage and 30 fertile controls were included in this study. Endometrial biopsy was performed precisely 7 days after LH surge. The cells density was expressed as percentage of positive immune cell/total stromal cells and the clustering of different endometrial cells was measured by R language toolbox 'spatstat'. Multiplex immunohistochemical method was employed to stain a panel of human endometrium samples simultaneously with antibodies against CD3 for T cells, CD20 for B cells, CD68 for macrophages and CD56 for uterine natural killer cells. The median CD3⁺, CD68⁺ and CD56⁺ cell density in the miscarriage group were significantly higher than those of the fertile controls. In addition, the clustering between CD56⁺ uterine natural killer cells and CD68⁺ macrophages in the miscarriage group was significantly increased compared with fertile controls. In conclusion, the significant change in numbers of three out of four endometrial immune cell density and a significant increase in clustering between CD68⁺ and CD56⁺ cells suggest that several immune cells and their interactions may be important in the function of the endometrium; abnormal interactions may predispose to recurrent miscarriage.

In vitro fertilization add-ons for the endometrium: it doesn't add-up

The probability of live birth from an in vitro fertilization (IVF) cycle is modest. Many additional treatments (add-ons) are available which promise to improve the success of IVF. This review summarizes the current evidence for common IVF add-ons which are suggested to improve endometrial receptivity. Systematic reviews of randomized controlled trials and individual trials were included. Five add-ons were included: immune therapies, endometrial scratching, endometrial receptivity array, uterine artery vasodilation, and human chorionic gonadotropin instillation. The results suggest there is no robust evidence that these add-ons are effective or safe. Many IVF add-ons are costly, consuming precious resources which may be better spent on evidence-based treatments or further IVF. Large randomized controlled trials and appropriate safety assessment should be mandatory before the introduction of IVF add-ons into routine practice.