In vitro fertilization outcome following embryo transfer with or without preinstillation of human chorionic gonadotropin into the uterine cavity: a randomized controlled trial

Immunomodulation for unexplained recurrent implantation failure: where are we now?

In brief

Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies.

Abstract

Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.

Does Intrauterine Injection of hCG Improve IVF Outcome? A Systematic Review and a Meta-Analysis

Various interventions have been proposed to improve embryo implantation in IVF. Among these, intrauterine injections of human chorionic gonadotropin seem to have promising results. Consequently, we conducted a review and meta-analysis to assess IVF outcomes by comparing couples who underwent intrauterine hCG injection transfer versus those who underwent embryo transfer with intrauterine injection of placebo, or without any additional intervention. The primary outcome was the clinical pregnancy rate. Secondary outcomes were the implantation rate, miscarriage rate, and live birth rate. A meta-analysis was conducted using the random effects model, while bias within studies was detected using the Cochrane risk of bias tool. Ectopic pregnancies and stillbirths were also assessed. The clinical pregnancy (RR 1.38, 95% CI 1.17−1.62, p < 0.0001) and implantation rate (RR 1.40, 95% CI 1.12−1.75, p = 0.003) were significantly higher in women who underwent hCG injection than in the control group. These significant effects persisted only in women who underwent cleavage-stage embryo transfer. No significant differences between groups were observed in the other secondary outcomes. In conclusion, our systematic review and meta-analysis demonstrate that intrauterine injection of hCG could be a valuable approach in women who undergo cleavage-stage embryo transfer. Given the lack of data about the live birth rate, caution should be exercised in interpreting these data.

The effect of intrauterine hCG injection before embryo transfer on pregnancy rate in frozen embryo transfer cycles

Objective

HCG (human chorionic gonadotropin), which is secreted by cytotrophoblast cells, plays an important role in improving pregnancy outcomes among patients with infertility or related problems. In this study, we evaluate the effect of intrauterine hCG injection prior to frozen embryo transfer on pregnancy outcomes.

Methods

In this clinical trial study, among women with infertility problems referred to (XXX) and those with frozen embryos were included in the study. 155 patients in the intervention group received 500 units of hCG while 157 in control group received saline prior to embryo transfer. Along with demographic data, successful in vitro fertilization and clinical pregnancy, loss of pregnancy, successful transplantation, and biochemical parameters were compared among the two groups.

Results

The mean age of the patients included in the study was 32.97 ± 3.31 years. The level of anti-Mullerian hormone, follicle stimulating hormone and the grade of frozen embryos were not significantly different between the two groups (P > 0.05). The rate of laboratory pregnancy in the intervention group was significantly higher than in the control group (51% vs 35%), p = 0.006. The rate of successful implantation and clinical pregnancy in the intervention group was also significantly higher, p = 0.01 and p = 0.006, respectively. Overall loss of pregnancy in intervention group was 78.1% and 86.0% in control group which was not significantly different, p = 0.068.

Conclusion

The outcomes of our study showed that 500 IU of hCG prior to embryo transfer improves the rate of clinical and laboratory pregnancy. However, it does not reduce the rate of loss of pregnancy. Further studies are therefore required in this area.

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HCG (human chorionic gonadotropin), which is secreted by cytotrophoblast cells.

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HCG plays an important role in improving pregnancy outcomes among patients with infertility.

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500 IU of hCG prior to embryo transfer improves the rate of clinical and laboratory pregnancy.

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Negative outcomes might not be affected in these groups.

Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses

BACKGROUND

Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists.

OBJECTIVE AND RATIONALE

We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes.

SEARCH METHODS

We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses.

OUTCOMES

Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs.

WIDER IMPLICATIONS

Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.

Effects of human chorionic gonadotropin intrauterine injection on oocyte retrieval day on assisted reproductive techniques outcomes: An RCT

Background

Several mediators play an important role in implantation. One of these mediators is human chorionic gonadotropin (HCG).

Objective

To evaluate the effects of HCG intrauterine injection on the day of oocyte retrieval on the result of assisted reproductive techniques (ART).

Materials and Methods

In this randomized clinical trial study, 126 women who were referred to Afzalipour Infertility Center between December 2018 to December 2019 undergoing in vitro fertilization/intracytoplasmic sperm injection cycles were enrolled and assigned to two groups of: a case (n = 62) and a control group (n = 64). The protocols for both groups were the same; except that the case group was injected with the protocols for both groups were the same, except that the case group was injected with 1000 IU of HCG into uterine cavity following the oocyte puncture, while no medication was administered to the control group. The implantation rate, chemical pregnancy, clinical pregnancy, and abortion rates were compared between the two groups.

Results

Positive chemical pregnancy was seen in 15 (27.3%) cases of the case group and 14 (25.5%) of the control group. No significant difference was seen in the chemical and clinical pregnancy rates between the groups. The abortion rate was higher in the control group but that was not significant.

Conclusion

A 1000 IU of HCG intrauterine injection after oocyte retrieval does not improve implantation, chemical or clinical pregnancy rates in ART cycles. Further studies are needed to clearly understand the role of HCG intrauterine injection in the day of oocyte retrieval in ART outcomes.

Approaches to Improve Endometrial Receptivity in Case of Repeated Implantation Failures

Repeated implantation failures are a constant challenge in reproductive medicine with a significant impact both on health providers and on infertile couples. Several approaches have been proposed so far as effective; however, accumulative data have clarified that most of the treatment options do not have the evidence base for a generalized application to be suggested by the relevant societies. Implantation failures are attributed to either poor quality embryos or to defected endometrial receptivity. The current review aims to summarize in a systematic way all the new trends in managing RIF via interference with endometrial receptivity. The authors focus mainly, but not exclusively, on endometrial injury prior to embryo transfer and endometrial priming with autologous cells or biological agents. To this direction, a systematic search of the Pubmed database has been conducted taking into account the emerged evidence of the last two decades. All the suggested interventions are herein presented and analyzed in terms of reproductive outcomes. It is evident that properly powered and designed randomized trials are needed to support a new standard approach in RIF treatment that will safely be incorporated in national and international guidelines.

Intramuscular injection of human chorionic gonadotropin prior to secretory transformation in patients undergoing frozen-thawed embryo transfer cycles

BACKGROUND

The major difference between a natural cycle and an artificially prepared cycle is the lack of luteinizing hormone (LH) peak in the latter. The LH/hCG receptors were identified to express in human endometrium and evidences of experiments also suggested the beneficial role of hCG in embryo implantation, indicating that the LH peak might be of clinical significance and the activation of LH/hCG receptors in the endometrium could improve embryo implantation. Hence, we postulated that the addition of hCG prior to secretory transformation in an artificial cycle might improve pregnancy outcomes.

METHODS

This retrospective cohort study was conducted at a Reproductive Medicine Center between 2016 and 2018. Patients aged ≤43 years at the (index) oocyte retrieval and undergoing artificially prepared frozen-thawed embryo transfer (FET) with at least one good-quality embryo transferred were included. The cycles were divided into two groups: The hCG group (n = 337) received an intramuscular injection of 10,000 IU hCG before secretory transformation; the control group (n = 364) performed FET without hCG administration. The primary endpoint was live birth delivery rate (LBR), secondary outcomes included implantation rate, clinical pregnancy rate (CPR) and ongoing pregnancy rate (OPR).

RESULTS

The LBR (49.9% vs 39.6%, P < 0.01), CPR (61.4% vs 50.5%, P < 0.01) and OPR (52.8% vs 43.1%, P < 0.05) were statistically significantly higher in the hCG group than the control group. The superiority in LBR after hCG administration remained significant after adjusting for confounding factors (OR 1.613, 95% CI 1.173-2.217; P < 0.01). In the subgroup analysis, the improvement in LBR was statistically significant after hCG administration for cleavage-stage embryo transfer cycles (51.2% vs 42.3%, P < 0.05), whereas for blastocyst transfer cycles, the improvement in LBR was not (45.7% vs 31.3%, P > 0.05).

CONCLUSIONS

Intramuscular hCG injection prior to secretory transformation may benefit LBR in patients undergoing artificially prepared FET cycles. But it should be noted that nonsignificant tendency towards higher LBR was observed after hCG administration in patients undergoing blastocyst transfer. So, future prospective randomized controlled studies are required to confirm, especially for blastocyst transfer cycles.

Intrauterine injection of human chorionic gonadotropin before embryo transfer can improve in vitro fertilization-embryo transfer outcomes: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate whether intrauterine injection of hCG before embryo transfer can improve IVF-ET outcomes.

DESIGN

Meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertile women who underwent IVF-ET and received an intrauterine injection of hCG before ET.

INTERVENTION(S)

Infertile women treated with or without intrauterine hCG injection before ET.

MAIN OUTCOME MEASURE(S)

The primary outcomes were live birth rate (LBR), ongoing pregnancy rate (OPR), and clinical pregnancy rate (CPR), and the secondary outcomes were implantation rate (IR) and miscarriage rate (MR). Odds ratios with 95% confidence intervals (CIs) and successful ET rates were pooled to determine the effects of hCG on IVF-ET outcomes.

RESULT(S)

Fifteen randomized controlled trials (RCTs) with a total of 2,763 participants were included. Infertile women in the experimental group (treated with intrauterine hCG injection before ET) exhibited significantly higher LBR (44.89% vs. 29.76%), OPR (48.09% vs. 33.42%), CPR (47.80% vs. 32.78%), and IR (31.64% vs. 22.52%) than those in the control group (intrauterine injection of placebo or no injection). Furthermore, MR was significantly lower (12.45% vs. 18.56%) in the experimental group than in the control group.

CONCLUSION(S)

The findings of this meta-analysis indicate that intrauterine injection of hCG can improve LBR, OPR, CPR, and IR after IVF-ET cycles. In addition, different timing and dosages of hCG administration may exert different effects on IVT-ET outcomes. Notably, infertile women treated with 500 IU hCG within 15 minutes before ET can achieve optimal IVF-ET outcomes.

Investigating the Optimal Time for Intrauterine Human Chorionic Gonadotropin Infusion in Order to Improve IVF Outcome: A Systematic Review and Meta-Analysis

BACKGROUND/AIM

Studies on the impact of intrauterine human Chorionic Gonadotropin (hCG) administration in order to improve the In Vitro Fertilization (IVF) outcome have yielded conflicting results. The aim of the present systematic review and meta-analysis is to investigate whether timing of intrauterine hCG administration prior to embryo transfer affects its efficiency.

MATERIALS AND METHODS

A systematic search of the literature on Pubmed/Medline, Embase and Cochrane databases was performed. Only Randomized Control Trials were included in this meta-analysis.

RESULTS

Live birth rates were not improved following hCG administration (RR=1.13, 95%CI=0.88-1.46, p=0.34) in the pooled results. Combined live birth and ongoing pregnancy rates were borderline statistically significant following hCG administration (RR=1.27, 95%CI=1.00-1.62, p=0.05). Following subgroup analysis regarding live birth and ongoing pregnancy rates, only the 5-12 minutes prior to the embryo transfer group reported a statistically significant improvement.

CONCLUSION

Intrauterine infusion of hCG within an IVF-Intracytoplasmic Sperm Injection (ICSI) cycle improves outcome only when administered 5-12 min prior to embryo transfer.

The Effect of Intrauterine Administration of Human Chorionic Gonadotropin (hCG) Before Embryo Transfer During Assisted Reproductive Cycles: a Meta-Analysis of Randomized Controlled Trials

The fertility success rates of clinical and laboratory-assisted reproductive techniques (ART) remain low, despite major advances. The aim of this study was to conduct a systematic literature review and assess whether the intrauterine administration of human chorionic gonadotropin (hCG) before embryo transfer (ET) improved the clinical outcomes of sub-fertile women undergoing assisted reproduction. The electronic databases PUBMED, EMBASE and Web of Science were systematically searched for randomized controlled trials (RCTs) published from inception to June 2018. The trial data were independently extracted and analyzed using risk ratios (RRs) and 95% confidence intervals (CIs) according to a random- or fixed-effect model (as appropriate), and a meta-analysis was conducted using Review Manager 5.2 software. The meta-analysis included 3241 patients from 12 RCTs, and the combined results demonstrated that intrauterine hCG injection significantly improved the rates of clinical (RR = 1.33; 95% CI: 1.12 – 1.58) and ongoing pregnancy (RR = 1.87; 95% CI: 1.54 – 2.27), compared with controls. However, intrauterine hCG injection had no significant effect on the implantation rate (RR = 1.30; 95% CI: 0.89 – 1.90), abortion rate (RR = 1.06; 95% CI: 0.78 – 1.44), ectopic pregnancy rate (RR = 0.77; 95% CI: 0.17 – 3.42) or live birth rate (RR = 0.99; 95% CI: 0.60 – 1.63). In a subgroup analysis, the intrauterine injection of > 500 IU hCG led to a significant increase in the implantation rate (RR = 1.64; 95% CI: 1.04 – 2.61) relative to controls. Furthermore, the subgroup of women with cleavage-stage ETs who received an intracavity injection of hCG (IC-hCG) exhibited increases in the implantation, clinical pregnancy and ongoing pregnancy rates, compared to women with cleavage-stage ETs and no IC-hCG. The current evidence indicates that intrauterine hCG administration before ET provides an advantage in terms of the clinical pregnancy and ongoing pregnancy rates.

Effect of intrauterine injection of human chorionic gonadotropin before frozen-thawed embryo transfer on pregnancy outcomes in women with endometriosis

Objective

To investigate the effect of human chorionic gonadotropin (hCG) intrauterine injection before frozen–thawed embryo transfer (FET) in women with endometriosis.

Methods

This retrospective cohort study included 45 women with endometriosis who underwent hCG intrauterine injection before FET; each woman was matched with three patients with endometriosis who did not receive hCG intrauterine injection (controls). Data on pregnancy and prenatal outcomes were extracted from medical records and compared.

Results

Patients in the hCG intrauterine injection group had significantly higher rates of pregnancy and clinical pregnancy (64.4% and 57.8%, respectively) than controls (47.4% and 39.3%, respectively). Neonatal birth weight for both singletons and twins was significantly higher in the hCG group (3486 ± 458 g and 2710 ± 437 g, respectively) than in the control group (3195 ± 401 g and 2419 ± 370 g, respectively).

Conclusion

Pregnancy rate, clinical pregnancy rate, and birth weight were improved in women with endometriosis who underwent intrauterine hCG injection compared with those who did not receive hCG before FET.

Intrauterine infusion of human chorionic gonadotropin before embryo transfer in IVF/ET cycle: The critical review

Intrauterine infusion of human chorionic gonadotropin (IUI-hCG) has been proposed to improve the outcome of in vitro fertilization-embryo transfer (IVF-ET), since it plays a critical role in synchronizing endometrial and fetal development. As the early mediator from embryo, hCG promotes the decidualization, angiogenesis, maternal immune tolerance, and trophoblast invasion, favoring successful implantation of embryo. Although multiple clinical trials have been conducted to verify the efficacy of IUI-hCG on IVF-ET outcome in recent years, the findings remained controversial. The difference in study design and population might be the cause to the different consequences after administration of hCG. More importantly, the endometrial receptivity, which might affect the efficacy of IUI-hCG, has not been assessed in women receiving this intervention. Selecting the right population suitable for IUI-hCG based on known etiology would be crucial in enhancing its efficacy and minimize any possible complications. Investigation of optimal indications for IUI-hCG should be highlighted in the future.

Intrauterine administration of human chorionic gonadotropin improves the live birth rates of patients with repeated implantation failure in frozen-thawed blastocyst transfer cycles by increasing the percentage of peripheral regulatory T cells

INTRODUCTION

Repeated implantation failure (RIF) frustrates both patients and their clinicians. Our aim was to observe the effects of intrauterine administration of human chorionic gonadotropin (hCG) on pregnancy outcomes of patients who received frozen-thawed embryo transfer (FET).

METHODS

A prospective cohort study was conducted to evaluate the impact of intrauterine administration of hCG on pregnancy outcomes in FET cycles of patients with RIF from January 1st 2016 to December 31st 2016. The treatment group (n = 153, 152 cycles) received an infusion of 500 IU of hCG diluted in normal saline 3 days before embryo transfer. The control group (n = 152, 151 cycles) received embryo transfer with a previous intrauterine injection of normal saline without hCG. Early morning fasting blood samples were obtained from each patient for the measurement of peripheral regulatory T cells (Tregs) on the day of embryo transfer. The outcome parameters including Tregs in each group were compared.

RESULTS

The patients in the hCG-treated group had significantly higher clinical pregnancy rates, implantation rates and live birth rates than the controls (37.5% versus 25.17%, 29.19% versus 19.4%, 26.97% versus 17.22%, respectively). They also had significantly higher percentages of peripheral Tregs than the controls (6.1 ± 0.6% versus 5.4 ± 1.0%). In addition, the clinical pregnancy rate, implantation rate and live birth rate in patients who received blastocyst transfer were significantly higher in the hCG-treated group when compared to the control group (41.38% versus 26.44%, 42.22% versus 26.14%, 33.33% versus 17.24%, respectively). We also showed that the clinical pregnancy rate, implantation rate and live birth rate were significantly higher in hCG-treated group when compared to the control group (49.12% versus 28.07%, 49.15% versus 28.07%, 40.35% versus 17.54%, respectively) of RIF patients with blastocyst transfer under 35 years, while there was on difference in patients above 35 years.

CONCLUSIONS

Intrauterine administration of hCG significantly improves the clinical pregnancy rate, implantation rate and live birth rate in FET cycles of patients with RIF by increasing Tregs. The treatment improves the pregnancy outcomes much more for younger RIF patients transferred blastocysts.

Soluble LH-HCG receptor and oestradiol as predictors of pregnancy and live birth in IVF

RESEARCH QUESTION

Circulating soluble LH-HCG receptor (sLHCGR) is a first-trimester marker for screening pregnancy pathologies and predicts premature or multiple births before fertility treatment. Oestradiol per oocyte at ovulation induction predicts IVF treatment outcomes. We asked whether sLHCGR levels are stable during fertility treatment and whether, alone or with oestradiol, they could improve prediction of fertility treatment outcomes.

DESIGN

Serum sLHCGR, anti-Müllerian hormone [AMH] and oestradiol were measured in patients undergoing IVF. Antral follicle count before ovarian stimulation and oocyte yield were used to establish sLHCGR- oocyte ratio (SOR), sLHCGR- antral follicle ratio (SAR), oestradiol at trigger per oocyte (oestradiol-oocyte ratio [EOR]) and oestradiol at trigger per antral follicle (oestradiol-antral follicle ratio [EAR]).

RESULTS

The relatively stable sLHCGR was negatively related to AMH when oocyte yield was high. The sLHCGR levels were proportional (r = 0.49) to oestradiol at early cycle (day-3). Pregnancy and live birth were highest at low sLHCGR (≤1.0 pmol/ml) and SOR (≤ 0.1 pmol/ml/oocyte). A total of 86-89% of live births in IVF treatment were within the cut-off parameters of SAR and SOR (0.5 pmol/ml) and EAR and EOR (380 pg/ml). For failed pregnancy, age, SOR and EOR together had positive and negative predictive values of 0.841 and 0.703, respectively.

CONCLUSIONS

sLHCGR levels are negatively related to AMH when oocyte yield is high. High early cycle sLHCGR is associated with elevated day-3 oestradiol. Low sLHCGR and SOR are indicators of increased clinical pregnancy and live birth rates. Patient age and SOR, combined with EOR, might improve prediction of IVF treatment outcomes.

Increased implantation rate after intrauterine infusion of a small volume of human chorionic gonadotropin at the time of embryo transfer: a randomized, double-blind controlled study

PURPOSE

Intrauterine human chorionic gonadotropin (hCG) infusion at the time of embryo transfer (ET) has resulted in controversial results. We evaluated the effects of intrauterine infusion of a small volume of hCG at the time of ET in fresh and frozen-thawed cycles.

METHODS

Infertile women scheduled for ET with either fresh or frozen-thawed cycles were enrolled and randomized into two groups (n = 100 each): an hCG group, who received 500 IU of hCG in 10 µL culture medium infused into the uterine cavity using a soft catheter 4 min before ET; and a control group, who received 10 µL of culture medium alone by the same technique. The primary outcome was the implantation rate. The secondary outcomes were clinical pregnancy and live birth rate.

RESULTS

Two hundred infertile women aged 18-43 years, undergoing fresh or frozen-thawed ET were enrolled, regardless of any previous transfer cycles. The implantation rate was significantly higher in the hCG group compared with the control group (28.8% vs. 18.2%, p = 0.030). The clinical pregnancy rates were similar in both groups (42% vs. 30%, p = 0.077). The live birth rates were also similar (29% and 23% in the hCG and control group, respectively).

CONCLUSIONS

Intrauterine infusion of a small volume of hCG at the time of ET can significantly improve the implantation rate, while the clinical pregnancy rate may only be improved in younger patients (aged < 40 years). This technique may thus be of benefit to patients undergoing clinical infertility treatment.

Intrauterine administration of human chorionic gonadotropin (hCG) for subfertile women undergoing assisted reproduction

BACKGROUND

Most women undergoing assisted reproduction treatment will reach the stage of embryo transfer (ET), but the proportion of embryos that can be successfully implanted after ET has remained small since the mid-1990s. Human chorionic gonadotropin (hCG) is a hormone that is synthesised and released by the syncytiotrophoblast and has a fundamental role in embryo implantation and the early stages of pregnancy. Intrauterine administration of hCG via ET catheter during a mock procedure around the time of ET is a novel approach that has been suggested to improve the outcomes of assisted reproduction.

OBJECTIVES

To investigate whether intrauterine (intracavity) administration of hCG (IC-hCG) around the time of ET improves clinical outcomes in subfertile women undergoing assisted reproduction.

SEARCH METHODS

We performed searches on 9 January 2018 using Cochrane methods.

SELECTION CRITERIA

We looked for randomised controlled trials (RCTs) evaluating IC-hCG around the time of ET, irrespective of language and country of origin.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data from studies, and attempted to contact study authors when data were missing. We performed statistical analysis using Review Manager 5. We assessed evidence quality using GRADE methods. Primary outcomes were live birth and miscarriage; secondary outcomes were clinical pregnancy rate and complications.

MAIN RESULTS

Seventeen RCTs investigated the effects of IC-hCG administration for 4751 subfertile women undergoing assisted reproduction. IC-hCG was administered in variable doses at different times before the ET. hCG was obtained from the urine of pregnant women or from cell cultures using recombinant DNA technology.Most studies (12/17) were at high risk of bias in at least one of the seven domains assessed. Common problems were unclear reporting of study methods and lack of blinding. The main limitations for evidence quality were high risk of bias and serious imprecision.For analyses of live birth and clinical pregnancy, there was considerable heterogeneity (I² > 75%) and therefore we present subgroups for dosage and stage of ET. Exploration for sources of heterogeneity revealed two key prespecified variables as important determinants: stage of ET (cleavage vs blastocyst stage) and dose of IC-hCG (< 500 international units (IU) vs ≥ 500 IU). We performed meta-analyses within subgroups defined by stage of embryo and dose of IC-hCG.Live birth rates among women having cleavage-stage ET with an IC-hCG dose < 500 IU compared to women having cleavage-stage ET without IC-hCG showed no benefit of the intervention and would be consistent with no substantive difference or disadvantage of indeterminate magnitude (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.58 to 1.01; one RCT; 280 participants; I² = 0%; very low-quality evidence). In a clinic with a live birth rate of 49% per cycle, use of IC-hCG < 500 IU would be associated with a live birth rate ranging from 28% to 50%.Results show an increase in live birth rate in the subgroup of women undergoing cleavage-stage ET with an IC-hCG dose ≥ 500 IU compared to women having cleavage-stage ET without IC-hCG (RR 1.57, 95% CI 1.32 to 1.87; three RCTs; 914 participants; I² = 0%; moderate-quality evidence). At a clinic with a live birth rate of 27% per cycle, use of IC-hCG ≥ 500 IU would be associated with a live birth rate ranging from 36% to 51%.Results show no substantive differences in live birth among women having blastocyst-stage ET with an IC-hCG dose ≥ 500 IU compared to women having blastocyst-stage ET without IC-hCG (RR 0.92, 95% CI 0.80 to 1.04; two RCTs; 1666 participants; I² = 0%; moderate-quality evidence). At a clinic with a live birth rate of 36% per cycle, use of IC-hCG ≥ 500 IU would be associated with a live birth rate ranging from 29% to 38%.Evidence for clinical pregnancy among women having cleavage-stage ET with an IC-hCG dose < 500 IU showed no benefit of the intervention and would be consistent with no substantive difference or disadvantage of indeterminate magnitude (RR 0.88, 95% CI 0.70 to 1.10; one RCT; 280 participants; I² = 0%; very low-quality evidence).Results show an increase in clinical pregnancy rate in the subgroup of women having cleavage-stage ET with an IC-hCG dose ≥ 500 IU compared to women having cleavage-stage ET without IC-hCG (RR 1.49, 95% CI 1.32 to 1.68; 12 RCTs; 2186 participants; I² = 18%; moderate-quality evidence).Results show no substantive differences in clinical pregnancy among women having blastocyst-stage ET with an IC-hCG dose ≥ 500 IU (RR 0.99, 95% CI 0.85 to 1.15; four RCTs; 2091 participants; I² = 42%; moderate-quality evidence) compared to women having blastocyst-stage ET with no IC-hCG.No RCTs investigated blastocyst-stage ET with an IC-hCG dose < 500 IU.We are uncertain whether miscarriage was influenced by intrauterine hCG administration (RR 1.04, 95% CI 0.81 to 1.35; 11 RCTs; 3927 participants; I² = 0%; very low-quality evidence).Reported complications were ectopic pregnancy (four RCTs; 1073 participants; four events overall), heterotopic pregnancy (one RCT; 495 participants; one event), intrauterine death (three RCTs; 1078 participants; 22 events), and triplets (one RCT; 48 participants; three events). Events were few, and very low-quality evidence was insufficient to permit conclusions to be drawn.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that women undergoing cleavage-stage transfer using an IC-hCG dose ≥ 500 IU have an improved live birth rate. There is insufficient evidence for IC-hCG treatment for blastocyst transfer. There should be further trials with live birth as the primary outcome to identify the groups of women who would benefit the most from this intervention. There was no evidence that miscarriage was reduced following IC-hCG administration, irrespective of embryo stage at transfer or dose of IC-hCG. Events were too few to allow conclusions to be drawn with regard to other complications.

Effect of intrauterine injection of human chorionic gonadotropin before fresh embryo transfer on IVF and ICSI outcomes: a meta-analysis

Purpose

This analysis was performed to evaluate the effects of intrauterine injection of human chorionic gonadotropin (hCG) before fresh embryo transfer (ET) on the outcomes of in vitro fertilization and intracytoplasmic sperm injection.

Methods

Randomized controlled trials (RCTs) were identified by searching electronic databases. The outcomes of live birth, clinical pregnancy, implantation, biochemical pregnancy, ongoing pregnancy, ectopic pregnancy, and miscarriage between groups with and without hCG injections were analyzed. Summary measures were reported as risk ratios (RR) with 95% confidence intervals.

Results

Six RCTs on fresh embryo transfer (ET) were included in the meta-analysis. A total of 2759 women undergoing fresh ET were enrolled (hCG group n = 1429; control group n = 1330). Intrauterine injection of hCG significantly increased rates of biochemical pregnancy (RR 1.61) and ongoing pregnancy (RR 1.58) compared to controls. However, there were no significant differences in clinical pregnancy (RR 1.11), implantation (RR 1.17), miscarriage (RR 0.91), ectopic (RR 1.65) or live birth rates (RR 1.13) between the hCG group and control group.

Conclusion

The current evidence for intrauterine injection of hCG before fresh ET does not support its use in an assisted reproduction cycle.

The effect of intrauterine human chorionic gonadotropin flushing on live birth rate after vitrified-warmed embryo transfer in programmed cycles: a randomized clinical trial

PURPOSE

To assess the influence of intrauterine human chorionic gonadotropin (hCG) before embryo transfer on the clinical pregnancy and live birth rates after vitrified-warmed embryo transfer (ET) in programmed cycles.

METHODS

This study was a single-blind randomized clinical trial for eligible patients underwent frozen ET cycles with long-term hormonal GnRH agonist protocol for endometrial preparation. Immediately prior to ET, the women were randomly divided into three groups. In the experimental group, 7-10 min before embryo transfer, 500 IU of hCG with a 40 μL of culture medium was injected into the uterus. In the first control (sham) group, 7-10 min before ET just 40 μL of culture medium intrauterine was infused. In the second control group, no intervention was done. The pregnancy outcomes were compared in the three groups using appropriate statistical tests.

RESULTS

Finally, 180 patients allocated into three groups. There was no significant difference in terms of patients 'characteristics among three groups. No significant difference was found in terms of clinical pregnancy among three groups. The miscarriage rate in control group (0%) was significantly lower than those of in the sham and hCG groups (9.8% and P = 0.01, 6.6% and P = 0.04, respectively). In addition, live birth rate (39.3%) in control group was significantly higher than those of in the sham and hCG groups (16.4% and P = 0.005, 23% and P = 0.051, respectively).

CONCLUSION(S)

It was found that intrauterine injection of 500 IU hCG before vitrified-warmed ET at cleavage stage has no beneficial effect on pregnancy outcome and is not suggested. NCT02355925.

Effects of intrauterine perfusion of human chorionic gonadotropin in women with different implantation failure numbers

PROBLEM

The aim of this research was to investigate the effects of the intrauterine perfusion of hCG before a frozen-thawed embryo transfer (FET) in women with different implantation failure numbers.

METHOD OF STUDY

This was a retrospective analysis of patients undergoing FET who received an intrauterine injection hCG 1000 IU before embryo transfer. The groups included women with their first implantation failure (A group, n = 26), second implantation failure (B group, n = 122), and three or more failures (C group, n = 77). Corresponding control groups (no infusion) were also included. The pregnancy rates were compared among these groups.

RESULTS

After intrauterine injection hCG, the biochemical pregnancy rates were 92.30%, 63.11%, 49.02%, and the clinical pregnancy rates were 76.92%, 54.91%, 48.05%, in the A, B, and C groups, respectively. The biochemical and clinical pregnancy rates were significantly higher in the A group than in the other groups (P < .05). The clinical pregnancy rates of the A and C groups were significantly higher than in the corresponding (no infusion) control groups (76.92% vs 56.81% and 48.05% vs 33.33%, P < .05).

CONCLUSION

Pregnancy rates decreased with the number of transplant failures. The intrauterine administration of hCG before FET significantly improved the pregnancy rates, especially after one and three or more implantation failures.

Outcome of intracytoplasmic sperm injection after preinstillation of a gonadotropin releasing hormone agonist in the uterine cavity just before embryo transfer

OBJECTIVE

To evaluate the effects of a gonadotropin releasing hormone agonist (GnRHa) injection prior to embryo transfer on implantation and pregnancy rate.

MATERIALS AND METHODS

We performed a retrospective analysis of patients undergoing in vitro fertilization (IVF) therapy with and without GnRHa preinstallation into the uterine cavity just before embryo transfer between January 2012 and March 2013 in a single IVF center of a university hospital. Patients were evaluated based upon implantation, pregnancy, live birth, and miscarriage rates.

RESULTS

GnRHa was injected into the uterine cavity of 108 patients prior to embryo transfer which were regarded as study group. One thousand forty-seven patients who were not injected GnRHa were regarded as the control group. Pregnancy rates were 44.4% and 41.7% in the GnRHa and control groups, respectively. Live birth rates were 27.8% and 26.1%, miscarriage rates were 15.7% and 15.7%, and implantation rates were 31% and 30%, respectively and there were no difference between groups statistically (p>0.05).

CONCLUSION

No statistically significant differences in implantation, pregnancy, live birth, or miscarriage rates were observed in patients treated with GnRHa prior to embryo transfer, relative to the controls. Therefore, GnRHa injection into the uterine cavity prior to embryo transfer is not recommended as a means of increasing implantation or pregnancy rates in IVF. However, prospective randomized controlled studies are needed to clarify the effect of GnRHa instillation in the uterine cavity for embryo implantation in IVF.

Effect of Increased Endometrial Thickness and Implantation Rate by Granulocyte Colony-Stimulating Factor on Unresponsive Thin Endometrium in Fresh In Vitro Fertilization Cycles: A Randomized Clinical Trial

BACKGROUND

The correlation between endometrial thickness and receptivity has been mentioned in various studies. This study investigated the effect of granulocyte colony-stimulating factor in treating thin endometrium of infertile women who were chosen for in vitro fertilization in our infertility clinic in 2014 and 2015.

METHODS

In this randomized clinical trial, 28 women who were chosen for in vitro fertilization and had endometrial thickness of less than 6 mm on the day of human chorionic gonadotropin (hCG) injection were included in the study. They were randomly divided into two groups: investigation and control groups. In investigation group (n = 13) one granulocyte colony-stimulating factor vial (300 micrograms in 1 mL) was infused into the uterus within five minutes by embryo transfer catheter. In control group (n = 15) 1 mL of saline was injected into the uterus with the same catheter.

RESULTS

There were significant differences between the two groups in terms of means of endometrial thickness on oocyte retrieval day (P = 0.001), embryo transfer day (P = 0.001), hCG injections (P = 0.001), and implantation rates (P = 0.001).

CONCLUSION

Granulocyte colony-stimulating factor can increase endometrial thickness in women treated with in vitro fertilization. RCT Code is 201406046063N2.

The effect of intrauterine HCG injection on IVF outcome: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of intrauterine HCG infusion before embryo transfer on IVF outcomes (live birth rate, clinical pregnancy rate and spontaneous aboretion rate) was investigated. Searches were conducted on MEDLINE, EMBASE and The Cochrane Library. Randomized studies in women undergoing IVF and intracytoplasmic sperm injection comparing intrauterine HCG administration at embryo transfer compared with no intrauterine HCG were eligible for inclusion. Eight randomized controlled trials were eligible for inclusion in the meta-analysis. A total of 3087 women undergoing IVF and intracytoplasmic sperm injection cycles were enrolled (intrauterine HCG group: n = 1614; control group: n = 1473). No significant difference was found in the live birth rate (RR 1.13; 95% CI 0.84 to 1.53) and spontaneous abortion rate (RR 1.00, 95% CI 0.74 to 1.34) between women who received intrauterine HCG and those who did not receive HCG. Although this review was extensive and included randomized controlled trials, no significant heterogeneity was found, and the overall included numbers are relatively small. In conclusion the current evidence does not support the use of intrauterine HCG administration before embryo transfer. Well-designed multicentre trials are needed to provide robust evidence.

Intrauterine administration of human chorionic gonadotropin (hCG) for subfertile women undergoing assisted reproduction

BACKGROUND

Subfertility affects 15% of couples and represents the inability to conceive naturally following 12 months of regular unprotected sexual intercourse. Assisted reproduction refers to procedures involving the in vitro handling of both human gametes and represents a key option for many subfertile couples. Most women undergoing assisted reproduction treatment will reach the stage of embryo transfer (ET) but the proportion of embryos that successfully implant following ET has remained small since the mid-1990s. Human chorionic gonadotropin (hCG) is a hormone synthesised and released by the syncytiotrophoblast and has a fundamental role in embryo implantation and the early stages of pregnancy. Intrauterine administration of synthetic or natural hCG via an ET catheter during a mock procedure around the time of ET is a novel approach that has recently been suggested to improve the outcomes of assisted reproduction.

OBJECTIVES

To investigate whether the intrauterine administration of hCG around the time of ET improves the clinical outcomes in subfertile women undergoing assisted reproduction.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Gynaecology and Fertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, registers of ongoing trials andreference lists of all included studies and relevant reviews (from inception to 10 November 2015), in consultation with the Cochrane Gynaecology and Fertility Group Trials Search Co-ordinator.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) evaluating intrauterine administration of hCG around the time of ET in this review irrespective of language and country of origin.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias, extracted data from studies and attempted to contact the authors where data were missing. We performed statistical analysis using Review Manager 5 in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. We assessed evidence quality using GRADE methods.

MAIN RESULTS

Twelve RCTs investigated the effect of intrauterine administration of hCG for 4038 subfertile women undergoing assisted reproduction. The intra-cavity hCG (IC-hCG) was administered in variable doses at different timings before the ET. The source of hCG was from the urine of pregnant women or from cell cultures using recombinant DNA technology.Most of the studies (9/12) were at high risk of bias in at least one of the seven domains assessed. Common problems were unclear reporting of study methods and lack of blinding. The main limitations in the overall quality of the evidence were high risk of bias and serious imprecision.For the analyses of live birth and clinical pregnancy, there was considerable heterogeneity (I(2) greater than 75%) and we did not undertake a meta-analysis. Exploration for the sources of heterogeneity identified two key pre-specified variables as important determinants: stage of ET (cleavage versus blastocyst stage) and dose of IC-hCG (less than 500 international units (IU) versus 500 IU or greater). We then performed meta-analysis for these analyses within the subgroups defined by stage of embryo and dose of IC-hCG.There was an increase in live birth rate in the subgroup of women having cleavage-stage ETs with an IC-hCG dose of 500 IU or greater compared to women having cleavage-stage ETs with no IC-hCG (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.32 to 1.87, three RCTs, n = 914, I(2) = 0%, moderate quality evidence). In a clinic with a live birth rate of 25% per cycle then the use of IC-hCG -500 IU or greater would be associated with a live birth rate that varies from 33% to 46%. We did not observe a significant effect on live birth in any of the other subgroups.The was an increase in clinical pregnancy rate in the subgroup of women having cleavage-stage ETs with an IC-hCG dose of 500 IU or greater compared to women having cleavage-stage ETs with no IC-hCG (RR 1.41, 95% CI 1.25 to 1.58, seven RCTs, n = 1414, I(2) = 0%, moderate quality evidence). We did not observe a significant effect on clinical pregnancy in either of the other subgroups.There was no evidence that miscarriage was influenced by intrauterine hCG administration (RR 1.09, 95% CI 0.83 to 1.43, seven RCTs, n = 3395, I(2) = 0%, very low quality evidence).Other complications reported in the included studies were ectopic pregnancy (three RCTs, n = 915, three events overall), heterotopic pregnancy (one RCT, n = 495, one event), intrauterine death (two RCTs, n = 978, 21 events) and triplets (one RCT, n = 48, three events). There was no evidence of a difference between the groups, but there were too few events to allow any conclusions to be drawn and the evidence was very low quality.

AUTHORS' CONCLUSIONS

The pregnancy outcome for cleavage-stage ETs using an IC-hCG dose of 500 IU or greater is promising. However, given the small size and the variable quality of the trials and the fact that the positive finding was from a subgroup analysis, the current evidence for IC-hCG treatment does not support its use in assisted reproduction cycles. A definitive large clinical trial with live birth as the primary outcome is recommended. There was no evidence that miscarriage was influenced by intrauterine hCG administration, irrespective of embryo stage at transfer or dose of IC-hCG. There were too few events to allow any conclusions to be drawn with regard to other complications.

The efficacy of intrauterine injection of human chorionic gonadotropin before embryo transfer in assisted reproductive cycles: Meta-analysis

OBJECTIVES

A systematic review and meta-analysis to evaluate the effect of human chorionic gonadotropin (hCG) intrauterine injection before embryo transfer on the outcome of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

METHODS

Searches of PubMed®, EMBASE®, EBSCO, Web of Science®, SCOPUS® and Cochrane Central Register of Controlled Trials were conducted to retrieve relevant randomized controlled trials (RCTs). Data were extracted and analysed.

RESULTS

The meta-analysis included five RCTs (hCG group n = 680; control group n = 707). Intrauterine hCG injection significantly increased rates of biochemical, clinical and ongoing pregnancy compared with controls. There were no between-group differences in implantation or miscarriage rates.

CONCLUSION

Women undergoing IVF/ICSI may benefit from intrauterine hCG injection before embryo transfer.