Combined analysis of endometrial thickness and pattern in predicting outcome of in vitro fertilization and embryo transfer: a retrospective cohort study

Improvement of endometrial thickness and in vitro fertilization outcomes in patients with Asherman's refractory endometrium using autologous mesenchymal stem cells from the stromal vascular fraction

OBJECTIVE

Patients with Asherman's Syndrome (AS) and an endometrial thickness (EMT) less than 7 mm are infertile women with suboptimal endometrium due to uterine scarring or endometrial atrophy. This study aimed to examine the effect of intrauterine injections of adipose-derived mesenchymal stem cells (ADMSC) from the Stromal Vascular Fraction (SVF) of adipose tissue on EMT and in vitro fertilization (IVF) outcomes: which are improvements in EMT and pregnancy rates.

METHODS

This double-arm retrospective study included 41 AS patients with hysteroscopic adhesiolysis. Twenty-one patients with AS refractory endometrium (Group 2) were given ADMSC to improve EMT, and 20 non-treated, age-matched patients served as controls (Group 1). For Group 2, SVF was isolated from 15 ml of adipose tissue and transmyometrial injected into the patient's uterine cavity. For all patients, EMT was examined using ultrasound before embryo transfer.

RESULTS

In Group 2, after ADMSC treatment, EMT significantly improved (3.2 ± 1.8 mm, P<0.001). Afterward, three patients spontaneously became pregnant, and eighteen underwent frozen embryo transfer. A significant increase in implantation (66.7% vs. 4.8%, P = 0.002) and live birth rates (0.0% vs. 47.6%, P = 0.001) were recorded. No significant difference was observed in EMT, cycle implantation, or clinical pregnancy between the two groups, but the live birth rate in Group 2 after ADMSC treatment was higher than in Group 1.

CONCLUSION

The results demonstrate that autologous intrauterine ADMSC injection can improve EMT, implantation, and pregnancy rates in AS patients with refractory endometrium. This research underscores the life-changing potential of autologous ADMSC treatment for patients with refractory endometrium, providing a promising avenue for future treatments.

A retrospective cohort study to examine factors affecting live birth after hysteroscopic treatment of intrauterine adhesions

OBJECTIVE

To evaluate independent factors that affect the chance of live birth (LB) after hysteroscopic adhesiolysis in patients with intrauterine adhesions.

DESIGN

Retrospective cohort study.

SETTING

Hysteroscopic center of Fuxing Hospital in Beijing, China.

PATIENT(S)

Patients diagnosed with Asherman syndrome between June 2020, and February 2022.

INTERVENTION(S)

Hysteroscopic adhesiolysis is followed by a second look hysteroscopy to assess the outcome and follow-up for a year.

MAIN OUTCOME MEASURE(S)

Live birth rate (LBR) without the use of assisted reproductive technologies at 12-month follow-up.

RESULT(S)

Of the 544 women included in the cohort, the pregnancy rate at the end of 1 year of follow-up was 47.6% (95% confidence interval [CI] 45.5%-49.7%), and the LBR was 41.0% (95% CI 38.9%-43.1%). Stepwise multiple logistic regression analysis identified three independent predictors of LB in decreasing order of significance: increase in menstrual flow after surgery (odds ratio [OR] 3.69, 95% CI 1.77-8.21), postoperative endometrial thickness in the midluteal phase (OR 1.53, 95% CI 1.31-1.80), and the severity of recurred adhesion at second-look hysteroscopy (OR 0.62, 95% CI 0.50-0.76). Among subjects with good independent prognostic factors, namely, increased menstrual flow after surgery, postoperative endometrial thickness in the midluteal phase >6 mm, and no or minimal recurrence of adhesions at second-look hysteroscopy, the LBR was 69.0% (95% CI 65.4%-72.6%). On the other hand, in women (n = 26) without any of the three good prognostic factors, none had a successful LB (0).

CONCLUSION(S)

Overall, the LBR after treatment for Asherman syndrome was 41.0%. The prognosis is dependent on three outcome measures after surgery, namely, improvement in menstrual flow, postoperative endometrial thickness, and the minimal degree of recurrent adhesions at second-look hysteroscopy.

Age-related increase in live-birth rates of first frozen thaw embryo versus first fresh transfer in initial assisted reproductive technology cycles without PGT

BACKGROUND

The landscape of assisted reproductive technology (ART) has seen a significant shift towards frozen-thawed embryo transfers (FET) over fresh transfers, driven by technological advancements and clinical considerations. This study aimed to compare live birth outcomes between primary FET and fresh transfers, focusing on cycles without preimplantation genetic testing (PGT), using United States national data from the SART CORS database spanning from 2014 to 2020.

METHODS

We performed a retrospective cohort study of autologous first ART cycles without PGT comparing primary embryo transfer (frozen thaw vs. fresh) success rates from the 2014-2020 SARTCORS database. Live-birth rates (LBR) and cumulative live-birth rates (CLBR) were compared between first FET versus first fresh embryo transfer from an index retrieval. Multivariate logistic regression (MLR) determined association between live birth outcomes and method of transfer. In a subsequent sub-analysis, we compared these two embryo transfer methods among patients with either diminished ovarian reserve (DOR) or male factor infertility.

RESULTS

228,171 first ART cycles resulted in primary embryo transfer. 62,100 initial FETs and 166,071 fresh transfers were compared. Initial FETs demonstrated higher LBR and CLBR compared to fresh transfers (LBR 48.3% vs. 39.8%, p < 0.001; CLBR 74.0% vs. 60.0%, p < 0.0001). MLR indicated greater chances of live birth with FET across all age groups, with adjusted odds ratio (aOR) of live-birth incrementally increasing with advancing age groups. For DOR cycles, LBR and CLBR were significantly higher for FET compared to fresh (33.9% vs. 26.0%, p < 0.001, 44.5% vs. 37.6%, p < 0.0001), respectively. MF cycles also demonstrated higher LBR and CLBR with FET (52.3% vs. 44.2%, p < 0.001, 81.2% vs. 68.9%, p < 0.0001), respectively. MLR demonstrated that in DOR cycles, initial FET was associated with greater chance of live birth in age groups ≥ 35yo (p < 0.01), with aOR of live birth increasingly considerably for those > 42yo (aOR 2.63, p < 0.0001).

CONCLUSIONS

Overall LBR and CLBR were greater for first FET than fresh transfers with incremental increases in odds of live birth with advancing age, suggesting the presence of a more favorable age-related change in endometrial receptivity present in frozen-thawed cycles. For both DOR and MF cycles, LBR and CLBR after primary transfer were greater for first FET than fresh. However, this was particularly evident in older ages for DOR cycles. This suggests that supraphysiologic stimulation in older DOR cycles may be detrimental to endometrial receptivity, which is in part corrected for in FET cycles.

Comparison of Letrozole and Clomiphene Citrate in Pregnancy Outcomes in Patients with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

Clomiphene citrate (CC) and letrozole are the predominant medical interventions for the management of infertility in patients with polycystic ovary syndrome (PCOS). To comprehensively summarize the evidence, a systematic review and meta-analysis of randomized clinical trials (RCTs) was carried out to assess the effect of letrozole and CC on pregnancy outcomes in PCOS patients. We searched PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials from inception to January 2023. We included RCTs conducted on PCOS women comparing letrozole to CC and assessing endometrial thickness, the number and size of follicles, and ovulation and pregnancy rates. The endpoints were summarized as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) using the random-effects model. Heterogeneity was examined using the I2 statistic. Fifty trials met our inclusion criteria. The mean endometrial thickness was significantly higher in the letrozole group compared to CC group (SMD: 0.89; 95% CI: 0.49, 1.28; I2=97.72%); however, the number of follicles was higher in the CC group (SMD: -0.56; 95% CI: -0.96, -0.17; I2=96.34%). Furthermore, letrozole intake induced higher ovulation rate (RR: 1.20; 95% CI: 1.13, 1.26; I2=54.49%) and pregnancy rate (RR: 1.44; 95% CI: 1.28, 1.62; I2=65.58%) compared to CC. Compared to CC, letrozole has a positive effect on endometrial thickness, monofollicular development, and ovulation and pregnancy rates suggesting that letrozole may be a strong alternative to CC as a first-line medical intervention for chronic anovulation in PCOS women. Larger studies are warranted to further clarify these findings.

When the Embryo Meets the Endometrium: Identifying the Features Required for Successful Embryo Implantation

Evaluation of the optimal number of embryos, their quality, and the precise timing for transfer are critical determinants in reproductive success, although still remaining one of the main challenges in assisted reproduction technologies (ART). Indeed, the success of in vitro fertilization (IVF) treatments relies on a multitude of events and factors involving both the endometrium and the embryo. Despite concerted efforts on both fronts, the overall success rates of IVF techniques continue to range between 25% and 30%. The role of the endometrium in implantation has been recently recognized, leading to the hypothesis that both the "soil" and the "seed" play a central role in a successful pregnancy. In this respect, identification of the molecular signature of endometrial receptivity together with the selection of the best embryo for transfer become crucial in ART. Currently, efforts have been made to develop accurate, predictive, and personalized tests to identify the window of implantation and the best quality embryo. However, the value of these tests is still debated, as conflicting results are reported in the literature. The purpose of this review is to summarize and critically report the available criteria to optimize the success of embryo transfer and to better understand current limitations and potential areas for improvement.

A prospective study on the endometrium properties and the pregnancy rate of infertile women with thin endometrium receiving Fructus ligustri lucidi used in traditional Chinese medicine

OBJECTIVE

To evaluate whether Zi Gui Nv Zhen capsules (ZGNZC) can increase the fertility rate of Chinese women with infertility due to thin endometrium.

METHODS

Prospective, randomized, open-labeled 3-monthly study; 104 patients (aged 20-40 years) receiving either ZGNZC (experimental group, n = 55) or not (control group, n = 49). Main outcomes: thickness/type of the endometrium during ovulation and pregnancy rate. Between-group analysis (A) compares the experimental vs. control group, and within-group analysis (B) compares data at baseline and after study in the experimental group.

RESULTS

(A) Between-group-analysis: Patients with ZGNZC had a higher endometrium thickness (0.8 ± 0.27 vs. 0.68 ± 0.10; p < .05) and higher type A endometrium rates (34.2% vs. 13.2%; p < .05) than the control group. Pregnancy rates were higher in the experimental than in the control group (43.6% vs. 22.4%; p < .05). (B) Within-group-analysis: ZGNZC increased endometrium thickness (0.58 ± 0.13 vs. 0.87 ± 0.24 vs. 0.83 ± 0.26 vs. 0.80 ± 0.27), and type A endometrium rates (10.9% vs. 60.0% vs. 49.0% vs. 34.2%) (all p < .05). Univariate analysis of pregnancy with other study parameters showed positive and significant correlations between pregnancy and administration of ZGNZC (p < .05). All hepato-renal biomarkers remained within the norm. There were no adverse events.

CONCLUSIONS

In infertile women with thin endometrium who wish to conceive, two months' application of ZGNZC can improve endometrial properties and proliferation, which is necessary for a healthy pregnancy, and increase the clinical pregnancy rate in our prospective randomized observational study.

Endometrial receptivity in women of advanced age: an underrated factor in infertility

BACKGROUND

Modern lifestyle has led to an increase in the age at conception. Advanced age is one of the critical risk factors for female-related infertility. It is well known that maternal age positively correlates with the deterioration of oocyte quality and chromosomal abnormalities in oocytes and embryos. The effect of age on endometrial function may be an equally important factor influencing implantation rate, pregnancy rate, and overall female fertility. However, there are only a few published studies on this topic, suggesting that this area has been under-explored. Improving our knowledge of endometrial aging from the biological (cellular, molecular, histological) and clinical perspectives would broaden our understanding of the risks of age-related female infertility.

OBJECTIVE AND RATIONALE

The objective of this narrative review is to critically evaluate the existing literature on endometrial aging with a focus on synthesizing the evidence for the impact of endometrial aging on conception and pregnancy success. This would provide insights into existing gaps in the clinical application of research findings and promote the development of treatment options in this field.

SEARCH METHODS

The review was prepared using PubMed (Medline) until February 2023 with the keywords such as 'endometrial aging', 'receptivity', 'decidualization', 'hormone', 'senescence', 'cellular', 'molecular', 'methylation', 'biological age', 'epigenetic', 'oocyte recipient', 'oocyte donation', 'embryo transfer', and 'pregnancy rate'. Articles in a language other than English were excluded.

OUTCOMES

In the aging endometrium, alterations occur at the molecular, cellular, and histological levels suggesting that aging has a negative effect on endometrial biology and may impair endometrial receptivity. Additionally, advanced age influences cellular senescence, which plays an important role during the initial phase of implantation and is a major obstacle in the development of suitable senolytic agents for endometrial aging. Aging is also accountable for chronic conditions associated with inflammaging, which eventually can lead to increased pro-inflammation and tissue fibrosis. Furthermore, advanced age influences epigenetic regulation in the endometrium, thus altering the relation between its epigenetic and chronological age. The studies in oocyte donation cycles to determine the effect of age on endometrial receptivity with respect to the rates of implantation, clinical pregnancy, miscarriage, and live birth have revealed contradictory inferences indicating the need for future research on the mechanisms and corresponding causal effects of women's age on endometrial receptivity.

WIDER IMPLICATIONS

Increasing age can be accountable for female infertility and IVF failures. Based on the complied observations and synthesized conclusions in this review, advanced age has been shown to have a negative impact on endometrial functioning. This information can provide recommendations for future research focusing on molecular mechanisms of age-related cellular senescence, cellular composition, and transcriptomic changes in relation to endometrial aging. Additionally, further prospective research is needed to explore newly emerging therapeutic options, such as the senolytic agents that can target endometrial aging without affecting decidualization. Moreover, clinical trial protocols, focusing on oocyte donation cycles, would be beneficial in understanding the direct clinical implications of endometrial aging on pregnancy outcomes.

A critical appraisal of studies on endometrial thickness and embryo transfer outcome

A receptive endometrium is required for successful embryo implantation. Endometrial thickness, as measured by ultrasonography, is the most commonly used marker of endometrial receptivity in assisted reproductive technology cycles. Several factors simultaneously affect both endometrial thickness and probability of live birth, including age, oestradiol concentration and oocyte number, among others. Most of the studies investigating a relationship between endometrial thickness and embryo transfer outcomes are retrospective and do not adequately address confounding factors, in addition to other limitations. Despite multiple meta-analyses and studies with large numbers of cycles, controversy still exists. The difference between the results from prospective and retrospective studies is also striking. This article presents a critical appraisal of the studies on endometrial thickness and embryo transfer outcomes in order to highlight methodological issues and how they can be overcome in future studies. Currently available evidence does not seem to support a modification of management just because endometrial thickness is below an arbitrary threshold.

Effect of tamoxifen in patients with thin endometrium who underwent frozen-thawed embryo transfer cycles: a retrospective study

Introduction

Thin endometrium leads to an impaired implantation rate. The aim of the study is to compare the clinical outcomes of tamoxifen (TAM) and hormone replacement therapy (HRT) used in patients with thin endometrium (<7mm) in frozen-thawed embryo transfer (FET)cycles.

Methods

A total of 176 FET cycles with thin endometrium were retrospectively analyzed in our center from Jan 2020 to May 2022. According to patients' own will, 112 patients were allocated to the HRT group and 64 patients chose the TAM protocol. Clinical outcomes were compared between two groups.

Result

The duration of treatment was shorter in the TAM group(12.03±2.34d) than the HRT group (16.07±2.52 d), which was statistically different (p<0.05). The endometrial thickness on the transfer day of the TAM group (7.32±1.28 mm) was significantly thicker than that of the HRT group (6.85±0.89mm, p<0.05). The clinical pregnancy rate of the TAM group (50.0%) was higher than that of the HRT group (36.6%), but there was no significant difference (p >0.05). The early miscarriage rate was significantly lower in the TAM group compared with the HRT group (5.9% Vs 26.8%, adjusted OR 0.10, p<0.05), while the live birth rate was higher in the TAM group (46.9% Vs 26.8%, adjusted OR 2.24, p<0.05) compared with the HRT group.

Conclusion

For patients with thin endometrium, TAM effectively improved the endometrial thickness and increased the live birth rate. TAM can be used as an alternative protocol for patients with thin endometrium.

Hyperbaric oxygen therapy: a possible choice for patients with resistant thin endometrium during frozen embryo transfer treatments

BACKGROUND

Thin endometrium is considered suboptimal for embryo implantation, leading to compromised pregnancy rates without effective therapies. While some studies have reported promoted endometrial growth after a period of hyperbaric oxygen therapy (HBOT) in patients with intrauterine adhesion, there have been no reports in patients with resistant thin endometrium. The purpose of this study was to investigate the impact of HBOT on endometrium growth and pregnancy outcomes in patients with resistant thin endometrium during frozen embryo transfer (FET) treatments.

METHODS

This prospective pre-post cohort study was conducted at a university-affiliated assisted reproductive medical center between October 2021 and December 2022. Patients who had experienced at least one canceled transfer cycle due to a thin endometrium(< 7 mm) on the endometrium transformation day, despite the use of standard therapies as well as adjuvant therapies, were enrolled in the study. Patients were assigned voluntarily to either the HBOT group or the concurrent control group. The HBOT group received daily HBOT for at least 10 days during the proliferative phase, in addition to the routine endometrium preparation methods and the concurrent control group underwent cycles without HBOT. Propensity score matching (PSM) was used to ensure comparability between the groups. Both self-control and case-control comparisons were conducted. The primary outcome measured was endometrial thickness (ET) on the day of endometrium transformation. Secondary outcomes included intrauterine pregnancy rate (IPR), embryo implantation rate (IR), miscarriage rate, and others.

RESULTS

Patients in the HBOT group demonstrated a significantly thicker endometrial thickness on the day of endometrium transformation after undergoing therapy (5.76 ± 1.66 vs. 6.57 ± 1.23, P = 0.002). This improvement was accompanied by a decreased rate of cycle cancellations. Baseline parameters and endometrial thickness were comparable between the HBOT group and the concurrent control group during the cycle. The IPR was similar in patients who received cleavage-stage embryos (0.0% vs. 6.7%, P = 1.00), but significantly higher in patients in the HBOT group who received blastocysts (53.8% vs. 18.2%, P = 0.017).

CONCLUSIONS

A period of HBOT prior to endometrium transformation contributes to increased endometrial thickness and facilitates blastocyst implantation in patients with resistant thin endometrium during FET treatments.

TRIAL REGISTRATION

The trial was registered on the Chinese Clinical Trial Registry (registration no. ChiCTR2300072831, retrospectively registered).

Suitable endometrial thickness on embryo transfer day may reduce ectopic pregnancy rate and improve clinical pregnancy rate

BACKGROUND

This retrospective study aimed to investigate the most suitable endometrial thickness (EMT) on the day of embryo transfer that could reduce ectopic pregnancy rate (EPR) and improve clinical pregnancy rate (CPR) in fresh embryo transfer patients with early follicular phase long-acting regimen.

METHODS

A total of 11,738 IVF/ICSI cycles, comprising 4,489 non-clinical pregnancies, 7,121 intrauterine pregnancies, and 128 ectopic pregnancy cycles after fresh embryo transfer, recorded between September 2017 and December 2020. Clinical pregnancy (CP) and ectopic pregnancy (EP) were the primary outcomes. Multivariate logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for EP and CP. Patients were divided into three groups based on the EMT (6-10 mm, 11-15 mm, and 16-20 mm). CPR and EPR per millimeter of EMT were drawn into a line chart, and three groups were analyzed by Chi-square test.

RESULTS

After controlling for potential confounders, EMT had a significant effect on CP (aOR = 1.07; 95% CI, 1.05-1.08; P = 0.00) and EP (aOR = 0.88; 95% CI, 0.82-0.94; P = 0.00). With the increase of EMT, CPR increased and EPR decreased. Pearson correlation coefficients were r = 0.708 (P = 0.00) and r =-0.558 (P = 0.03), respectively. Significant differenceswere detected in the CPRs and EPRs (all P = 0.00). The CPR in the 6-10 mm group (54.88%) was significantly lower than that in the 11-15 mm group (64.23%) and the 16-20 mm group (64.40%) (P = 0.00). The EPR in the 6-10 mm group (2.72%) was significantly higher than that in the other two groups (1.60% and 0.97%, P = 0.00). The difference in CPR and EPR between the 11-15 mm group and the 16-20 mm group was not statistically significant, which indicated that EMT ≥ 11 mm simultaneously reduced the EPR and increased the CPR.

CONCLUSIONS

EMT was inversely proportional to EPR and directly proportional to CPR in fresh embryo transfer cycles. The EMT ≥ 11 mm on the day of embryo transfer could simultaneously achieve lower EPR and higher CPR. Accordingly, more attention should be given to the EMT of women who underwent ART treatment.

The Cystic Anechoic Zone of Uterine Cavity Newly Observed during Controlled Ovarian Hyperstimulation Affects Pregnancy Outcomes of Fresh Embryo Transfer

During controlled ovarian hyperstimulation (COH), cystic anechoic zones in the uterine cavity are occasionally visible. This retrospective matched cohort study collected information on patients who underwent in vitro fertilization/intracytoplasmic injection (IVF/ICSI) from January 2014 to December 2020 at our center. The propensity score algorithm matched 179 cases that had uterine cystic anechoic zones, with 358 which did not have uterine cystic anechoic zones cases. After matching, the live birth rate (38.0% vs. 48.6%, p = 0.025) of patients with uterine cystic anechoic zones was lower than that in the no uterine cystic anechoic zone group, while for clinical pregnancy miscarriage rate (22.2% vs. 12.4%, p = 0.031), the rate was higher. The results showed no correlation in the association between live birth rate (r = −0.027, p = 0.718), clinical pregnancy rate (r = −0.037, p = 0.620) or biochemical pregnancy rate (r = −0.015, p = 0.840) and the diameters of the cystic anechoic zones in the uterine cavity. There was a significant difference in the type of endometrium between the two groups (p < 0.001). The result of this study can provide guidance to patients on whether to undergo fresh embryo transfer in the current cycle.

Comparison of clinical effects between early follicular prolonged GnRH agonist protocol and GnRH antagonist protocol in 3310 cycles: a retrospective study

BACKGROUND

It is the duty of doctors to choose a safe, simple, economic and effective controlled ovulation stimulation (COS) protocol for the patients. This study aims to compare the clinical effects of the early follicular prolonged GnRH agonist (EFPL) and GnRH antagonist (GnRH-Ant) protocols, hoping to provide some reference for clinicians when choosing COS program.

METHODS

A retrospective study included 3310 ovum pick up cycles undergoing assisted reproductive technology during January 2019 to May 2022 in Renmin Hospital of Wuhan University. Propensity Score Matching (PSM) and multivariable logistic regression analysis were used to improve the comparability between the two protocols. Subgroups were divided according to age, body mass index (BMI) and anti-Mullerian hormone (AMH). The live birth rate (LBR) and clinical pregnancy rate (CPR) were the primary outcomes.

RESULTS

After PSM, the endometrial thickness, fresh embryo transplantation rate, chemical pregnancy rate, CPR were significantly higher in EFPL group than that in GnRH-Ant group (P < 0.001). The E2, LH, P values on trigger day were significantly lower in EFPL group (P < 0.001). The cycle cancellation rate was significantly reduced in EFPL group (P < 0.001). However, the total amount of Gn and duration of Gn were significantly increased in the EFPL group (P < 0.001). Multivariable logistic regression analysis showed that the LBR was significantly higher in EFPL group after matching [OR (95%CI), 1.86 (1.13, 3.05), P = 0.02], especially for those with age < 35 years [OR (95%CI), 1.95 (1.14, 3.34), P = 0.02], BMI < 24 kg/m² [OR (95%CI), 2.08 (1.14, 3.80), P = 0.02], AMH levels ≥ 4.5 ng/ml [OR (95%CI), 4.19 (1.53, 11.43), P < 0.01].

CONCLUSION

EFPL regimen is more suitable to elicit live birth for those young patients with BMI < 24 kg/m² and AMH ≥ 4.5 ng/ml. However, for patients with decreased ovarian reserve or advanced age, EFPL regimen has no advantage over the GnRH-Ant regimen.

Value of transvaginal three-dimensional ultrasound in evaluating the curative effect of Yangmo decoction in the treatment of uterine adhesion

OBJECTIVES

Intrauterine adhesions (IUA) is the damage of the basal layer of the endometrium caused by various reasons, resulting in adhesion of the uterine muscle walls to each other, which is manifested as clinical symptoms such as spanomenorrhea, amenorrhea, and infertility. Hysteroscopic adhesiolysis (HA) is the main treatment, for patients with moderate or severe adhesion or angular adhesion, the incidence of postoperative adhesion is high. Traditional Chinese medicine "Yangmo decoction" can promote endometrial growth. Three-dimensional transvaginal ultrasonography (3D-TVUS) can judge IUA and evaluate uterine receptivity through three-dimensional imaging. This study aims to investigate the value of 3D-TVUS in judging the efficacy of Yangmo decoction in the treatment of intrauterine adhesions.

METHODS

The clinical data of patients who underwent HA at two different centers in department of Gynecology of Third Xiangya Hospital of Central South University and Changsha Jiangwan Hospital from January 2021 to August 2021 were retrospectively collected. A total of 275 eligible patients were included. According to the postoperative management measures, the selected patients were divided into two groups. Yangmo decoction group (n=138): the use of Yangmo decoction and uterine-shaped silicon stent post HA; Hormone group (n=137): the use of estrogen, progesterone and uterine-shaped silicon stent post HA. The preoperative general data, preoperative and postoperative 3D-TVUS parameters of the two groups were analyzed.

RESULTS

The endometrial thickness of Yangmo decoction group was thicker than that of hormone group (P<0.001), the intercornual distance was wider (P=0.016), the endometrial echo was more homogeneous (P=0.018), the percentage of bilaterally visible tubal opening was higher (P<0.001), the endometrial morphology was better (P=0.012), and endometrial blood flow, endometrial motility and uterine motion were better in Yangmo decoction group than that in the hormone group (all P<0.001).

CONCLUSIONS

The endometrial thickness, echo, blood flow, and peristalsis, the number of visible tubal opening, uterine motion, and the intercornual distance obtained by 3D-TVUS examination are important factors to evaluate the prognosis of postoperative drug treatment for IUA. 3D-TVUS is of great significance in evaluating the efficacy of Yangmo decoction in the treatment of IUA.

Is early-follicular long-acting GnRH agonist protocol an alternative for patients with polycystic ovary syndrome undergoing in vitro fertilization?

BACKGROUND

We aimed to compare the clinical and perinatal outcomes of patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment with either an early-follicular long-acting gonadotropin-releasing hormone agonist (GnRH-a) long protocol (EFLL) or a midluteal short-acting GnRH-a long protocol (MLSL).

METHODS

This single-center, retrospective study, included patients with PCOS who underwent IVF/ICSI from January 2013 to June 2019 at the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. Patients underwent either MLSL (1179 cycles) or EFLL (2390 cycles). The primary outcomes were pregnancy outcomes, perinatal and maternal complications.

RESULTS

Fresh embryo transfer (59.12% vs. 55.47%, P = 0.038), clinical pregnancy (75.23% vs. 53.82%, P = 0.001), and live birth rates (63.27% vs. 42.05%, P = 0.010) were higher in the EFLL group. However, the proportion of patients "freezing all" for high risk of ovarian hyperstimulation syndrome (OHSS) (24.27% vs. 32.06%, P = 0.001) and ectopic pregnancy (1.51% vs. 5.97%, P = 0.002) were lower in the EFLL group than in the MLSL group. The incidence of gestational diabetes was higher in the EFLL group than in the MLSL group (5.08% vs. 1.42%, RR 3.714, 95% confidence interval (CI) 1.474-9.360, P = 0.003). There were no significant differences in the incidence of hypertension, premature rupture of membranes, placenta previa, congenital heart disease, or neonatal weight between the two groups. Logistic regression results showed that age (OR 0.966, 95% CI 0.941-0.993, P = 0.013), treatments (OR 2.380, 95% CI 1.833-3.089, P = 0.001), and endometrial thickness on trigger day (OR 1.115, 95% CI 1.070-1.162, P = 0.001) were correlated with clinical pregnancy. Pre-pregnancy BMI (OR 1.098, 95% CI 1.002-1.204, P = 0.046), fasting plasma glucose (FPG) (OR 3.096, 95% CI 1.900-5.046, P = 0.001), and treatments (OR 3.458, 95% CI 1.359-8.800, P = 0.009) were correlated with gestational diabetes mellitus (GDM). Treatments (OR 0.291, 95% CI 0.148-0.575, P = 0.001) and endometrial thickness on trigger day (OR 0.834, 95% CI 0.722-0.962, P = 0.013) were correlated with ectopic pregnancy.

CONCLUSION

The early-follicular long-acting GnRH agonist long protocol can be used as an ideal assisted reproductive technology (ART) pregnancy assistance program for patients with PCOS, but obese patients should be encouraged to lose weight before ART treatments to reduce the risk of GDM.

Transcutaneous electrical acupoint stimulation improves endometrial receptivity resulting in improved IVF-ET pregnancy outcomes in older women: a multicenter, randomized, controlled clinical trial

OBJECTIVE

To examine the effects and mechanisms of transcutaneous electrical acupoint stimulation (TEAS) on pregnancy outcomes in women undergoing in vitro fertilization (IVF)-embryo transfer (ET).

DESIGN, SETTING, AND PARTICIPANTS

This efficacy study was a multicenter, randomized, controlled clinical trial (RCT) in women receiving IVF-ET. The mechanistic study was a single-center RCT.

INTERVENTIONS

The participants received TEAS vs. no TEAS treatment.

MAIN OUTCOME MEASURES

In the efficacy study, the primary outcomes were the rates of clinical pregnancy, embryo implantation, and live birth. In the mechanistic study, sex hormones and endometrial protein expression were examined.

RESULTS

Ultimately, 739 participants were enrolled (367 and 372 in the TEAS and control groups, respectively). The clinical pregnancy rate was higher in the TEAS group than in the controls (55.1% vs. 46.7%, P = 0.03). There were no significant differences in embryo implantation, biochemical pregnancy, and live birth rates between the two groups (all P > 0.05) in the study population. In women > 35 years, the clinical pregnancy rates, embryo implantation rates and live birth rates in the TEAS and control groups were 48.9% vs. 23.7% (P = 0.004),30.8 vs. 13.9% (P = 0.001) and 34.0% vs. 19.7% (P = 0.06) respectively. In the mechanistic study with 120 participants, on the theoretical embryo implantation day, better developed endometrial pinopodes, elevated endometrial integrin α1β1/αVβ3, leukemia inhibitory factor, and elevated serum progesterone levels were found in the TEAS group compared with controls.

CONCLUSION

TEAS significantly improved the clinical pregnancy rate in women undergoing IVF-ET, especially in women of older age. It might be due to improved endometrial receptivity.

TRIAL REGISTRATION

ChiCTR-TRC-13003950.

Single Dose Gonadotropin-Releasing Hormone Agonist Luteal Support in Fresh Embryo Transfer: Variation in Timing, Type, and Dosage

Objectives

To evaluate the effects of the addition of single-dose GnRH agonist to the routine progestogens use for luteal phase support on IVF outcome as compared to progestogens only.

Methods

This is a retrospective case-control study on selected patients who underwent IVF treatment with fresh embryo transfer (ET) under Medically Assisted Conception Unit, University Kebangsaan Malaysia Medical Center for the period of June 2015–June 2018. A higher dose of 0.2 mg subcutaneous Decapeptyl was administered 2 days before fresh ET concurrent with routine progestogen support. Patients with different luteal phase regimes, frozen embryo transfer and medical records with missing data were excluded. Their medical records were reviewed, and data analyzed. The pregnancy outcomes measured included biochemical pregnancy rates, clinical pregnancy rates, live birth rates and miscarriage rates.

Results

A total of 786 patients were analyzed. Four hundred forty-four patients were given luteal phase support with progestogens and GnRH agonist, whereas 342 patients served as control were given progestogens only. The study group showed higher biochemical pregnancy rate (47.7 vs. 44.4%,), clinical pregnancy rate (25.7 vs. 23.4%) and livebirth rate (24.3 vs. 22.2%), respectively but not statistically significant. The rate of miscarriage among the study group was lower (4.5% vs 9.4%) compared to the progestogen group alone. Nonetheless, the OHSS rate was slightly increased in the study group (4.5 vs. 3.5%) despite using a mild stimulation protocol.

Conclusions

New regime of GnRH agonist luteal support in addition to the standard progestogen support was found to be beneficial in overall IVF outcome.

Supernumerary embryos, do they show the cycle success in a fresh embryo transfer? A retrospective analysis

OBJECTIVE

To determine the predictive value of cryopreserved embryos during single fresh blastocyst transfer.

METHODS

This retrospective cohort study was conducted at a tertiary university hospital ART center. Patients who underwent a single fresh blastocyst transfer were selected from the electronic database. Patients with diminished ovarian reserve, uterine pathology, advanced age (>40 years) were excluded from the study. Patients were divided into two groups. Group A consisted of patients with only one available embryo for the fresh transfer. Group B consisted of patients with cryopreserved embryos apart from the fresh transferred embryo. Demographic and embryology parameters, pregnancy results were compared.

RESULTS

Demographic values, ovarian reserve parameters were comparable between groups. The number of the picked-up oocyte, metaphase-2 oocyte, and two-pronucleus embryo was lower in Group A. Positive pregnancy rates were two-fold higher in Group B (23.4% vs. 50.9% p < .01). Pregnancy results did not change depending on the number of cryopreserved embryos in Group B.

CONCLUSION

According to our results, the presence of cryopreserved embryos results in higher pregnancy rates in patients with fresh blastocyst embryo transfer independent from the woman's age and ovarian reserve. Thus, these results may help us to predict the implantation rate before embryo transfer.

Ginseng adjuvant therapy on COVID-19: A protocol for systematic review and meta-analysis

BACKGROUND

Corona virus disease 2019 (COVID-19) is spreading fast and it brings great pressure to the social economy. Many reports revealed that ginseng can develop immunity for respiratory disease, but there is no evidence to prove its effects on COVID-19. This protocol of systematic review and meta-analysis will clarify the safety and effectiveness of ginseng adjuvant therapy on COVID-19 patients.

METHODS

Different databases (Web of Science, Cochrane Library, PubMed, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, Wan fang Database, ClinicalTrials, World Health Organization Trials, and Chinese Clinical Trial Registry) will be retrieved to search related articles according to pre-defined inclusion and exclusion criteria. Clinical recovery time and effective rates will be assessed as the primary outcomes and any changes of patient's condition will be considered as the secondary outcomes. Subgroup analysis and sensitivity analysis will be conducted to explore sources of heterogeneity. Endnote X9.3 will be used to manage data screening. The statistical analysis will be completed by RevMan5.3 and Stata/SE 15.1 software.

RESULTS

This study will assess the effects and safety for ginseng adjuvant therapy on COVID-19 patients.

CONCLUSION

The discussion will be considered to determine whether sufficient evidence exists to prove the effects of ginseng adjuvant therapy for COVID-19 patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (ID: CRD42021277843).

The Effect of Sildenafil Citrate on Poor Endometrium in Patients Undergoing Frozen-Thawed Embryo Transfer following Resection of Intrauterine Adhesions: A Retrospective Study

BACKGROUND

The recent studies have shown that sildenafil citrate can enhance estrogen-induced proliferation of the endometrium in infertile women.

OBJECTIVE

This study was aimed to investigate whether sildenafil citrate could affect pregnancy outcomes in infertile women receiving frozen-thawed embryo transfer (FET) after resection of intrauterine adhesions (IUAs).

MATERIALS AND METHODS

A total of 310 subjects who met the inclusion criteria were recruited and divided into the control group (group A) and the sildenafil citrate group (or the SC group, group B). The 2 groups were, respectively, divided into 2 subgroups based on the severity of reformed adhesions: (1) group A1 (with mild IUAs) and group A2 (with moderate to severe IUAs) and (2) group B1 (with mild IUAs) and group B2 (with moderate to severe IUAs). Therapeutic effects of sildenafil citrate on the cases were evaluated after resection of IUAs during FET cycles. Endometrial thickness, endometrial pattern, and pregnancy outcomes were evaluated and compared between the 2 groups.

RESULTS

There was no significant difference in the number of embryos transferred between the 2 groups. The endometrial thickness in group B (0.80 [0.68-0.90] cm) was significantly higher than that in group A (0.73 [0.35-0.80] cm). Besides, the biochemical pregnancy rate, clinical pregnancy rate, and live birth rate (LBR) were 71.60, 50.83, and 39.17% in group B, which were significantly higher than those in group A, namely, 57.36, 34.73, and 23.68%, respectively (p < 0.05). The univariate analysis and multivariate logistic regression showed that the LBR in either subgroups of group B after vaginal sildenafil treatment was significantly higher than that in the corresponding control group (p < 0.05).

CONCLUSIONS

It was observed that the administration of sildenafil citrate during FET could effectively improve the poor endometrial conditions after FET following the resection of IUAs.

Correlation between plasmatic progesterone, endometrial receptivity genetic assay and implantation rates in frozen-thawed transferred euploid embryos. A multivariate analysis

OBJECTIVE

To ascertain the predictive value of different parameters to determine endometrial receptivity among assisted reproduction treatments in which single embryo transfer of frozen-thawed euploid blastocysts are performed.

STUDY DESIGN

Observational study involving 104 patients recruited between September.2018 and June.2019 at a University associated assisted reproduction center. The relationship of different parameters (age, body mass index (BMI), duration of hormonal preparation, plasmatic progesterone levels, endometrial parameters at ultrasound assessment and endometrial receptivity determined by endometrial receptivity assay (ERA) was evaluated by a multivariable logistic (binomial) analysis after hormonal preparation. According to the ERA test results a personalized endometrial transfer (pET) was scheduled and live birth rate was assessed. Only single transfers of frozen euploid blastocysts were performed.

RESULTS

ERA test report predicted receptive endometrium (RE) in 54,64% patients and non-receptive (NR) in 45,31% patients. Among NR endometrial samples, 20,62% were classified as pre-receptive or early receptive, whereas 24,74% as post-receptive or late-receptive. The univariate analysis showed a relationship between BMI, doses of progesterone administered before biopsy and the receptivity of endometrium. There was no relationship between age of women, duration of hormonal supplementation, and the results of ERA test. In our series, endometrial receptivity was not related neither to endometrial thickness nor plasmatic progesterone levels. The multivariate analysis showed that both, BMI and cumulative progesterone administered prior to the test are independent predictive factors of endometrial receptivity (p = 0,047 and p = 0,034 respectively). The overall live birth rate after FET of euploid embryos was 62,35%. The odd of pregnancy was higher when ERA test was performed prior to the first embryo transfer (93,10% vs. 46,43%; OR = 15,58;95%CI 3,38-71,89). Overall, ongoing pregnancy rates showed a favorable trend after "non-receptive" endometria had been diagnosed and, thus, a modified (pET) preparation was performed (70,00% vs. 55,56%; OR = 1,87; 95% CI 0,76-4,57).

CONCLUSION

Regarding implantation potential of genetically screened blastocysts, the traditional tools used for assessing endometrial receptivity such as transvaginal evaluation of endometrial thickness and pattern or progesterone levels determination were not useful among our patients for predicting a receptive endometrium.

The Effect of Endometrial Thickness on Pregnancy, Maternal, and Perinatal Outcomes of Women in Fresh Cycles After IVF/ICSI: A Systematic Review and Meta-Analysis

BACKGROUND

Thin endometrium on ovulation triggering day is associated with impaired pregnancy outcomes in women after in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), but the role of thick endometrium on pregnancy outcomes remains controversial. Moreover, there has been insufficient evidence currently to analyze the influence of endometrial thickness (EMT) on obstetric complications and perinatal outcomes. Thus, we performed this meta-analysis to evaluate the effect of EMT on pregnancy, maternal, and perinatal outcomes in an enlarged sample size.

METHODS

The databases Pubmed, Embase, Cochrane Libraries, and Web of Science were searched for English articles evaluating the correlation between EMT and pregnancy, maternal, or perinatal outcomes in women who underwent IVF/ICSI. We included studies that depicted a clear definition of outcomes and EMT grouping on ovulation triggering day. The EMT effect was analyzed in fresh cycle. Qualities of studies were assessed by the Newcastle-Ottawa Scale (NOS). Odds ratios (ORs) and weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated for analyzing dichotomous and continuous outcomes respectively, under a fixed or random effect model.

RESULTS

A total of 22 pieces of literature were included for the final meta-analysis. A decreased trend towards pregnancy outcomes was observed, such as live birth rate (LBR), clinical pregnancy rate (CPR), and implantation rate (IR) in the thin endometrium groups (EMT <7 mm). In contrast, thick endometrium (EMT >14 mm) had no effect on pregnancy outcomes compared to medium EMT groups (EMT 7-14 mm). Moreover, thin endometrium (EMT <7.5 mm) enhanced the incidence of hypertensive disorders of pregnancy (HDP) and small-for-gestational-age (SGA) infants, and decreased the birthweight (BW) of babies.

CONCLUSIONS

Our studies indicated that thin endometrium not only had detrimental effect on pregnancy outcomes, but also increased the risk of HDP in women and SGA of babies, or decreased BW of babies. The thick endometrium does not have an adverse effect on IVF outcomes. Therefore, patients need to be informed on possible obstetric complications and perinatal outcomes caused by thin endometrium and are encouraged to actively cooperate with perinatal care.

SYSTEMATIC REVIEW REGISTRATION

(https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=242637), identifier CRD42021242637.

Effect of endometrial thickness and embryo quality on live-birth rate of fresh IVF/ICSI cycles: a retrospective cohort study

BACKGROUND

Successful implantation and delivery require both the functional embryo and receptive endometrium in assisted reproductive technology (ART) cycles. However, little is known about embryo-endometrial interaction on live-birth. We aimed to investigate the independent effect and interaction of endometrial thickness (EMT) and embryo quality on live-birth in fresh embryo transfer (ET) cycles.

METHODS

We conducted a retrospective cohort study including 15,012 ART cycles between 2013 and 2016 in three centers in China. Poisson regression with generalized estimating equations was employed to calculate relative risks (RRs) and 95% confidence intervals (CIs). We estimated the interaction of embryo quality and EMT on live-birth rate (LBR).

RESULTS

The LBR per cycle was 42.8% overall. LBR increased with increasing EMT and reached a plateau (50.6 to 54.2%) when EMT was 11 mm or thicker. Embryo quality represented by cumulative score was associated with LBR independently of number of embryos transferred and EMT. LBR was not increased with thicker EMT when only Q1 cleavage-stage embryo transferred (aRR 0.95, 95%CI 0.61-1.46). LBR was not increased significantly with thicker EMT with transfer of two good-quality cleavage-stage embryos and any blastocyst combination except Q1 group. There was significant interaction between EMT and embryo quality on LBR for cleavage-stage ETs (P=0.023).

CONCLUSIONS

This study demonstrated the nonlinear EMT-LBR association and the EMT cut-off value of 11 mm which may be of more clinical significance for predicting live-birth. Embryo quality is an independent prognostic tool for LBR. Our finding of significant embryo-endometrial interaction indicates combination of EMT and embryos quality might improve the prognostic value in clinical practice for live-birth in patients undergoing transfer of 1-2 fresh cleavage-stage embryos.

Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis

BACKGROUND

Early reproductive failure is the most common complication of pregnancy with only 30% of conceptions reaching live birth. Establishing a successful pregnancy depends upon implantation, a complex process involving interactions between the endometrium and the blastocyst. It is estimated that embryos account for one-third of implantation failures, while suboptimal endometrial receptivity and altered embryo-endometrial dialogue are responsible for the remaining two-thirds. Endometrial receptivity has been the focus of extensive research for over 80 years, leading to an indepth understanding of the processes associated with embryo-endometrial cross-talk and implantation. However, little progress has been achieved to translate this understanding into clinically meaningful prognostic tests and treatments for suboptimal endometrial receptivity.

OBJECTIVE AND RATIONALE

The objective of this systematic review was to examine the evidence from observational studies supporting the use of endometrial receptivity markers as prognostic factors for pregnancy outcome in women wishing to conceive, in order to aid clinicians in choosing the most useful marker in clinical practice and for informing further research.

SEARCH METHODS

The review protocol was registered with PROSPERO (CRD42017077891). MEDLINE and Embase were searched for observational studies published from inception until 26 February 2018. We included studies that measured potential markers of endometrial receptivity prior to pregnancy attempts and reported the subsequent pregnancy outcomes. We performed association and accuracy analyses using clinical pregnancy as an outcome to reflect the presence of receptive endometrium. The Newcastle-Ottawa scale for observational studies was employed to assess the quality of the included studies.

OUTCOMES

We included 163 studies (88 834 women) of moderate overall quality in the narrative synthesis, out of which 96 were included in the meta-analyses. Studies reported on various endometrial receptivity markers evaluated by ultrasound, endometrial biopsy, endometrial fluid aspirate and hysteroscopy in the context of natural conception, IUI and IVF. Associations were identified between clinical pregnancy and various endometrial receptivity markers (endometrial thickness, endometrial pattern, Doppler indices, endometrial wave-like activity and various molecules); however, their poor ability to predict clinical pregnancy prevents them from being used in clinical practice. Results from several modern molecular tests are promising and further data are awaited.

WIDER IMPLICATIONS

The post-test probabilities from our analyses may be used in clinical practice to manage couples' expectations during fertility treatments (IUI and IVF). Conventionally, endometrial receptivity is seen as a dichotomous outcome (present or absent), but we propose that various levels of endometrial receptivity exist within the window of implantation. For instance, different transcriptomic signatures could represent varying levels of endometrial receptivity, which can be linked to different pregnancy outcomes. Many studies reported the means of a particular biomarker in those who achieved a pregnancy compared with those who did not. However, extreme values of a biomarker (as opposite to the means) may have significant prognostic and diagnostic implications that are not captured in the means. Therefore, we suggest reporting the outcomes by categories of biomarker levels rather than reporting means of biomarker levels within clinical outcome groups.

Therapeutic role of granulocyte macrophage colony-stimulating factor (GM-CSF) in patients with persistent thin endometrium: A prospective and randomized study

OBJECTIVE

To assess the effect of granulocyte macrophage colony-stimulating factor (GM-CSF) on unresponsive thin (<7 mm) endometrium in women undergoing frozen-thawed embryo transfer.

METHODS

A single-center, randomized, prospective study enrolled 304 women with thin unresponsive endometrium from Shanghai Ninth People's Hospital between March 2017 and May 2018. Of them, 161 patients received an intrauterine infusion of GM-CSF and 143 patients served as controls. After hysteroscopy, a gel with or without GM-CSF was administered to fill the uterine cavity completely or up to 5 mL only. The primary outcome was confirmed pregnancy and secondary outcomes included endometrial thickness and implantation rate.

RESULTS

Patients who were administered GM-CSF had a significantly higher chemical pregnancy rate (35.3% vs 20.0%; P=0.009) and clinical pregnancy rate (28.6% vs 13.3%; P=0.005) compared with patients in the control group. Patients treated with GM-CSF had significantly higher endometrial thickness compared with controls (7.83 ± 1.45 mm vs 7.37 ± 0.70 mm, P=0.003).

CONCLUSION

GM-CSF therapy can effectively increase endometrial thickness and improve the clinical pregnancy rate in patients with persistent thin endometrium. The therapeutic role of GM-CSF for infertile women under in vitro fertilization and embryo transfer (IVF-ET) treatment can be further explored.

CHINESE CLINICAL TRIAL REGISTER

ChiCTR-IPR-17011242.

Does the ultrasound appearance of the endometrium during treatment with assisted reproductive technologies influence pregnancy outcomes?

We evaluated endometrial pattern, defined as the relative echogenicity of the endometrium on a longitudinal uterine ultrasonic section, as a surrogate for endometrial receptivity in an attempt to evaluate the association between endometrial pattern and pregnancy outcome in women who underwent ART treatment. The primary outcome was live birth and secondary outcomes were clinical intrauterine pregnancy and miscarriage. Potential associations were evaluated using cluster-weighted generalized estimating equations to account for within-couple correlation among repeated ART cycles while adjusting for potentially confounding variables. There were 1034 ART cycles with embryo transfer (778 fresh, 256 frozen) among 695 women (median age: 31.0 (6.0) years). The average number of embryos transferred per cycle was 2.1. The clinical intrauterine pregnancy rate per transfer was 56.0% for fresh and 54.3% for frozen cycles. The overall live birth rate per embryo transfer was 48.4%. Live birth rates were unchanged when the endometrium was semi-trilinear (RR:0.91 CI:0.74,1.12) or unilinear (RR:1.15 CI:0.89,1.49) in comparison to trilinear endometrium after controlling for potentially confounding variables. Results were similar when analysed separately for fresh and frozen cycles and when evaluating associations with clinical intrauterine pregnancy and miscarriage rates. It appears that endometrial pattern does not significantly affect live birth in ART and our data do not support cancelling an ART cycle if the endometrium is less than trilinear.

A randomized clinical trial of sildenafil plus clomiphene citrate to improve the success rate of ovulation induction in patients with unexplained infertility

OBJECTIVES

To investigate the role of sildenafil citrate in improving ovulation induction success rate in women with unexplained infertility.

METHODS

A randomized clinical trial from January to December 2018 of 80 women with unexplained infertility randomized into two groups. Both groups received 100 mg clomiphene citrate once daily from days 3-7 of the menstrual cycle. The study group also received 25 mg oral sildenafil citrate twice daily from days 8-12 of the same cycle. Transvaginal ultrasound assessed ovulation, endometrial thickness, and number of follicles. Pregnancy was assessed 2 weeks after ovulation. Primary outcome measures were endometrial thickness, number of mature follicles, and pregnancy rates.

RESULTS

Pregnancy rates (26 (65%) and 16 (40%), P=0.043) and endometrial thickness (10.4 ± 1.4 and 9.2 ± 1.9, P=0.007) were significantly higher in the study group. More women in the study group reported adverse effects compared with the control group (17 [42.5%] vs 9 [22.5%]; P=0.034), with headache the most common adverse effect in the study group, reported by 8 (20.0%) patients.

CONCLUSION

Adding sildenafil citrate improved ovulation success rate and increased pregnancy rate.

PAN AFRICAN CLINICAL TRIAL REGISTRY

PACTR201907658492123.

Predictive factors influencing pregnancy rate in frozen embryo transfer

PURPOSE

To evaluate the outcomes of embryo transfer (ET) and to identify the parameters influencing pregnancy outcomes.

METHODS

This study included 938 ET cycles involving single frozen and thawed good-quality blastocyst (Gardner grade ≥3BB) between August 2017 and January 2018. The significance of several parameters including endometrial thickness, position of the transferred air bubble, self-evaluation score by physicians, and uterus direction at ET as predictors of clinical pregnancy was evaluated using univariate and multivariate analyses.

RESULTS

Among 938 ET cycles, 462 (49.3%) resulted in a clinical pregnancy. Endometrial thickness was positively associated with clinical pregnancy in a linear trend. Between the variable position of the transferred air bubble and clinical pregnancy rate showed a curvilinear relationship. Clinical pregnancy rate was higher in cases with good self-evaluation score, whereas there was no difference between groups with different uterus directions. Univariate analysis of predictive parameters identified endometrial thickness, self-evaluation score by physicians, and position of air bubbles as significant predictors of clinical pregnancy, of which endometrial thickness and position of air bubbles appeared to be independently related to clinical pregnancy.

CONCLUSION

Endometrial thickness and the position of transferred air bubbles influenced clinical pregnancy in ET cycles.

The effect of icariin for infertile women with thin endometrium: A protocol for systematic review

BACKGROUND

Thin endometrium, defined as <7 mm of the endometrial thickness around ovulation period, had been identified as a negative factor on pregnancy rate of infertile women. It was considered to be the toughest part in treatment of infertility, because there was a lack of significant effect, although many drugs had been already used. Icariin was one of the major bioactive pharmaceutical constituent extracted from the Chinese herb "Ying Yang Huo," in the genus of Epimedium, and some randomized controlled trials reported its application for thin endometrium. There is no systematic review focusing on the effective of icariin in treating infertile women with thin endometrium, so our review aims to explore it.

METHODS

The bibliographic database and electronic library will be systematically searched online, such as MEDLINE, EMBASE, Web of Science, Clinicaltrails.org., China National Knowledge Infrastructure Database (CNKI), Wan fang Database, China Biology Medicine Database (CBM), VIP Science Technology Periodical Database, and Cochrane Library. And the reference listed for potential literatures of included studies will be scanned additionally. Related randomized controlled trials (RCTs) will be collected and selected before January 4, 2020. Trials will be screened by independent reviewers, and the literature will be search in English or Chinese, with the search terms as "Icariin," "Epimedium," "infertile women," "female infertility," "endometrium," "pregnancy rate." The software for Systematic review and Meta-analysis is RevMan 5.3. The protocol and the systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement.

RESULT AND CONCLUSION

The efficacy of icariin to treat thin endometrium will be evaluated, and the conclusion will be published to help clinicians determine treatment strategy for infertile women with thin endometirum by providing medical evidence.

REGISTRATION INFORMATION

PROSPERO CRD42019148977.

Effect of Endometrial Thickness Change in Response to Progesterone Administration on Pregnancy Outcomes in Frozen-Thawed Embryo Transfer: Analysis of 4465 Cycles

OBJECTIVE

To evaluate whether endometrial thickness (EMT) change in response to progesterone has an effect on pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles.

DESIGN

Retrospective observational study.

SETTING

Tertiary-care academic medical center.

PARTICIPANTS

4465 infertile women undergoing their first FET between January 2010 and December 2015 in our center.

METHODS

This observational study included 4465 patients undergoing their first FET cycles between January 2010 and December 2015. EMT was measured by transvaginal ultrasound one day before progesterone administration and on the day of FET to observe EMT change.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (CPR) and the live birthrate (LBR) was discussed.

RESULTS

Regardless of the endometrial preparation protocols such as artificial cycle, estrogen-progesterone replacement therapy (EP) or natural cycle (NC), EMT may increase, decrease or remain stable on the day of FET compared with that of one day before progesterone administration. CPR in EMT increase, decrease and stable groups were 48.4%, 51.3% and 50.7% in EP cycle versus 49.2%, 52.0% and 48.9% in NC cycle, showing no significant difference between the three groups in both cycles (P= 0.48, P= 0.49). LBR was 40.9%, 45.9% and 42.6% in EP cycle versus 44.2%, 44.8% and 42.1% in NC cycle, also showing no significant difference between the three groups in both cycles (P= 0.16, P= 0.66). In addition, CPR and LBR were not significantly associated with EMT increase.

CONCLUDES

EMT may increase, decrease or remain stable on the day of FET as compared with that of one day before progesterone administration. Whatever change in EMT that occurs after progesterone administration has no significant effect on CPR and LBR in FET cycles.

Analysis of the Number of Euploid Embryos in Preimplantation Genetic Testing Cycles With Early-Follicular Phase Long-Acting Gonadotropin-Releasing Hormone Agonist Long Protocol

Studies have shown that early-follicular phase long-acting gonadotropin-releasing hormone (GnRH) agonist long protocol (EFLL), a popular controlled ovarian hyperstimulation protocol widely used in China, leads to higher rates of implantation and clinical pregnancy, as well as lower rates of spontaneous abortion and ectopic pregnancy in patients undergoing in vitro fertilization treatment. However, the impact of EFLL on euploid embryos and its underlying mechanisms remain unclear. To address these gaps of knowledge, we conducted a retrospective comparative study of 310 preimplantation genetic testing (PGT) cycles with a total of 1,541 embryos using the EFLL protocol or midluteal short-acting GnRH agonist long protocol (MLSL). Patients were matched by PGT subtype [aneuploidies (PGT-A) vs. PGT for chromosomal structural rearrangements (PGT-SR)], age (±2 years), and body mass index (±1 kg/m²). For PGT-A, there was no significant difference in the number of euploid embryos (1.80 ± 1.47 for EFLL vs. 1.84 ± 2.03 for MLSL, p > 0.05) or the rate of euploidy (44.6 vs. 36.9%, p > 0.05). For PGT-SR, the number of euploid embryos in the EFLL group was significantly higher than that in the MLSL group (1.76 ± 1.54 vs. 1.21 ± 1.24, p < 0.05). A higher euploidy rate was also observed with the EFLL protocol compared with that obtained in MLSL (31.9 vs. 25.7%), although the difference was not statistically significant (p > 0.05). Compared with the MLSL protocol, more euploid embryos were achieved when using the EFLL protocol in PGT-SR, demonstrating the value in PGT-SR. To the best of our knowledge, this study is the first one to compare embryonic outcomes between EFLL and MLSL, providing key insights into the clinical application of EFLL in PGT cycles. In the light of the limited sample size of our study, we recommend that these questions be explored using a larger prospective study.

Efficacy and safety of platelet-rich plasma for the treatment of thin endometrium: A protocol for systematic review and meta-analysis

BACKGROUND

Endometrial thickness has been identified as a prognostic factor for pregnancy rate for patients with female infertility. Thin endometrium is defined as <7 mm on the day of ovulation, or on the day of human chorionic gonadotrophin (HCG) injection in fresh in vitro fertilization (IVF) cycles, or the day to start progesterone in frozen-thaw embryo transfer cycles, as stated in the guideline of thin endometrium from the Canadin Fertility and Andrology Society and Chinese expert consensus from the Society of Reproductive Medicine, Chinese Medical Association. Many medicines are used for improving the endometrial thickness and embryo implantation rate of the patients with thin endometirum, but thin endometrium remains a major troublesome clinical problem with limited efficacy.Platelet-rich plasma (PRP), as a growing and robust therapeutic option in musculoskeletal medicine, is a preparation of autologous plasma with a high concentration of platelets, and the therapeutic mechanism is based on the capacity to supply supra physiologic amounts of essential growth factors to provide a regenerative stimulus for promoting repair in tissues with low healing potential. Some randomized controlled trials have reported the application of PRP for patients with thin endometrium with satisfactory effect. However, there is no systematic review on efficacy and safety of PRP as a treatment of thin endometrium.

METHODS

The data and information will be retrieved from the databases of MEDLINE, Embase, Web of Science, Clinicaltrials.org., Cochrane Library, China Biology Medicine Database, Wan Fang Database, China National Knowledge Infrastructure Database, VIP Science Technology Periodical Database, and OpenGrey for gray literature. The randomized controlled clinical trials are going to be selected before December 20, 2019, in English or Chinese language, with the search terms including "thin endometrium,""platelet-rich plasma," "endometrial thickness," "hemorheology of endometrium," "pregnancy rate," and "adverse reactions." RevMan 5.3 will be used for systematic review and meta-analysis. This protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement, and the systematic review will be reported with the PRISMA statement.

RESULTS AND CONCLUSION

The efficacy and safety of PRP for the treatment of thin endometrium will be evaluated, and the conclusion will be published to provide medical evidence for a better clinical decision of patients with thin endometirum.

The impact of endometrial thickness change after progesterone administration on pregnancy outcome in patients transferred with single frozen-thawed blastocyst

BACKGROUND

The aim of this study was to explore the impact of endometrial thickness change after progesterone administration on pregnancy outcome in patients transferred with single frozen-thawed blastocyst.

METHODS

This observational cohort study included a total of 3091 patients undergoing their first frozen-thawed embryo transfer (FET) cycles between April 2015 to March 2019. Endometrial thickness was measured by trans-vaginal ultrasound twice for each patient: on day of progesterone administration, and on day of embryo transfer. The change of endometrial thickness was recorded.

RESULTS

Regardless of endometrial preparation protocol (estrogen-progesterone/natural cycle), female age, body mass index (BMI), and infertility diagnosis were comparable between patients with an increasing endometrium on day of embryo transfer and those without. However, clinical pregnancy rate increases with increasing ratio of endometrial thickness. Compared with patients with Non-increase endometrium, those with an increasing endometrium on day of embryo transfer resulted in significantly higher clinical pregnancy rate (56.21% vs 47.13%, P = 0.00 in estrogen-progesterone cycle; 55.15% vs 49.55%, P = 0.00 in natural cycle).

CONCLUSIONS

In most patients, endometrial thickness on day of embryo transfer (after progesterone administration) increased or kept being stable compared with that on day of progesterone administration. An increased endometrium after progesterone administration was associated with better pregnancy outcome.

Factors affecting pregnancy outcomes following the surgical removal of intrauterine adhesions and subsequent in vitro fertilization and embryo transfer

This study aimed to investigate the clinical factors affecting pregnancy rates following the surgical removal of intrauterine adhesions (IUAs) and subsequent in vitro fertilization and embryo transfer (IVF-ET). We retrospectively evaluated case data from patients who had undergone hysteroscopic surgery to remove varying degrees of IUAs and who had subsequently received assisted reproductive treatments with IVF-ET (in all 140 cycles) at our hospital between January, 2011 and January, 2015. The patient data were divided into either the pregnancy or non-pregnancy groups based on the pregnancy outcomes, and a number of clinicopathological variables were compared these two groups, such as age, infertility (type and duration), the number of prior surgical treatments for and severity of IUAs, the baseline follicle-stimulating hormone/luteinizing hormone (FSH/LH) ratio and estradiol level, endometrial thickness on the day of human chorionic gonadotropin (hCG) administration, etc. We selected the variables with statistically significant differences to generate multivariate logistic regression and linear correlation analyses. We found that i) the mean endometrial thickness on the day of hCG administration was greater in the pregnancy group, and that the average gestational age was younger than that in the non-pregnancy group. The different age groups had significantly different pregnancy rates. The mean baseline FSH/LH ratio of the women in the pregnancy group was lower than that in the women in the non-pregnancy group. The number of embryos transferred in the pregnancy group was higher than that in the non-pregnancy group. However, the other variables exhibited similar values between these two groups. ii) Our multivariate logistic regression analyses revealed that age and endometrial thickness on the day of hCG administration had significant effects on the pregnancy outcome. The baseline FSH/LH ratio and the number of embryos transferred were similar between the groups. On the whole, age and endometrial thickness on the day of hCG administration are the most important predictors of pregnancy outcome in the patients undergoing IVF-ET following the surgical removal of IUAs. Importantly however, the identification of effective methods with which to improve the endometrial thickness and the ovarian response in patients with diminished ovarian reserves warrants further investigation in future research.

Endometrial thickness and IVF cycle outcomes: a meta-analysis

RESEARCH QUESTION

In this meta-analysis, the association between endometrial thickness (EMT) and cycle outcomes after IVF is explored. Associations between EMT and cycle outcomes according to study and individual characteristics were also assessed.

DESIGN

Studies evaluating associations between EMT and pregnancy, implantation, miscarriage, live birth or ongoing pregnancy and ectopic pregnancy rates in individuals after IVF were identified on PubMed, Embase and the Cochrane Library (from their inception up to December 2018). Pooled odds ratios with 95% confidence intervals, calculated using the random-effects model, were used.

RESULTS

Nine prospective and 21 retrospective studies, including a total of 88,056 cycles, were retrieved. The summary odds ratios indicated that women with lower EMT were associated with lower pregnancy rates than those with higher EMT (n = 30, OR 0.61; 95% CI 0.52 to 0.70; P < 0.001). Moreover, the implantation rate in women with lower EMT was significantly reduced (n = 9, OR 0.49; 95% CI 0.32 to 0.74; P = 0.001). Furthermore, no significant association was found between EMT and the miscarriage rate (n = 12). In addition, women with lower EMT were associated with reduced live birth or ongoing pregnancy rate (11 studies, OR 0.60; 95% CI 0.48 to 0.73; P < 0.001). Finally, the incidence of ectopic pregnancy rate between lower and higher EMT showed no statistically significant association (n = 3).

CONCLUSIONS

Lower EMT was associated with lower pregnancy, implantation and live birth or ongoing pregnancy rates.

Embryo transfer strategy and therapeutic options in infertile patients with thin endometrium: a systematic review

Human endometrium has a key role in implantation process. The measurement of endometrial thickness is the most commonly used in clinical practice. Managing patients with thin endometrium still represents a major challenge for clinicians. The objective of this systematic review was to investigate all available interventions to improve endometrial thickness (EMT) in women with history of thin endometrium undergoing fresh or frozen-thawed embryo transfers (ET). We performed a comprehensive search of relevant studies from January 1978 to February 2018. The different strategies were categorized as hormonal, vascular, and growth factor approaches and specifically analyzed according to the type of ET. Thirty-one studies were included. Overall, quality of the evidence ranged from very low to moderate, with only few randomized controlled trials that support the use of either GnRH analogues in fresh ET or sildenafil in frozen ET for enhancing endometrial growth. Besides, intensified estradiol administration is a common approach that might improve EMT in frozen ET. The present review evidences the paucity of reliable data regarding the efficiency of different interventions aiming at increasing EMT before fresh or frozen-thawed ET. Robust and high-quality randomized controlled trials are still needed before guidelines can be established.

Mild starting dosage ovarian stimulation combined with a modified prolonged GnRH-a protocol improved IVF/ICSI outcomes in normal ovarian responders

INTRODUCTION

Controlled ovarian hyperstimulation (COH) is essential for artificial reproduction technology (ART). This study aimed to evaluate the effects of a mild starting dosage of r-FSH ovarian stimulation after the modified prolonged GnRH-a down-regulation protocol for COH on the clinical outcomes in normal ovarian responders undergoing in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET).

MATERIAL AND METHODS

In the retrospective study, the patients were separated into two groups according to the starting dosage of r-FSH: a mild dosage group (75 IU ≤ r-FSH < 150 IU, n = 858) and a conventional dosage group (150 IU ≤ r-FSH ≤ 225 IU, n = 535). Data were collected from clinical records. The baseline characteristics and clinical outcomes were compared between the two groups.

RESULTS

Although the duration of r-FSH treatment was a little longer in the mild dosage group, the total r-FSH dosage and the cost of ovarian stimulation were significantly lower than those in the conventional dosage group. Furthermore, compared to the conventional dosage group, the number of retrieved oocytes was also lower in the mild dosage group, whereas the rates of two pronuclei (2PN) fertilized oocytes and good-quality embryos were remarkable higher. The implantation rate, clinical pregnancy rate and live birth rate were significantly higher in the mild dosage group. There was no difference in early miscarriages rate, incidence of moderate and severe ovarian hyper-stimulation syndrome (OHSS) or incidence of ectopic pregnancy between the two groups.

CONCLUSIONS

The modified prolonged GnRH-a pituitary down-regulation regimen combined with mild r-FSH starting dosage improved IVF/ICSI outcomes and reduced the financial cost in normal ovarian responders.

Management of thin endometrium in assisted reproduction: a clinical practice guideline from the Canadian Fertility and Andrology Society

The impact and management of thin endometrium is a common challenge for patients undergoing assisted reproduction. The objective of this Canadian Fertility and Andrology Society (CFAS) guideline is to provide evidence-based recommendations using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework on the assessment, impact and management of thin endometrium in assisted reproduction. The effect of endometrial thickness on pregnancy and live birth outcomes in ovarian stimulation and IVF (fresh and frozen cycles) is addressed. In addition, recommendations on the use of adjuvants to improve endometrial thickness and pregnancy outcomes are provided.

Innovations in assisted reproductive technologies: impact on contemporary donor egg practice and future advances

Innovations in assisted reproductive technologies (ART) have driven progress in the donor egg field since the birth of the first baby derived from a donor egg in 1983. Over time, donor oocytes have become an increasingly used option for patients unable to conceive with autologous oocytes. In donor egg, the unique separation of the oocyte source and recipient uterus has created a model that has propelled advances in ART. Progressive ART innovations that have optimized the oocyte donor and resulting embryo include the following: evaluation of ovarian reserve, controlled ovarian hyperstimulation regimens that reduce the risk of ovarian hyperstimulation syndrome, blastocyst culture, oocyte cryopreservation, and preimplantation genetic testing. For donor egg recipients, methods to optimize the endometrium to maximize implantation include endometrial receptivity testing, immunologic donor-recipient matching, and increased understanding of the uterine microbiome.

Transcutaneous electrical acupuncture point stimulation improves pregnancy outcomes in patients with recurrent implantation failure undergoing in vitro fertilisation and embryo transfer: a prospective, randomised trial

Objective:

To evaluate the effect of transcutaneous electrical acupuncture stimulation (TEAS) on pregnancy outcomes in patients with recurrent implantation failure (RIF) undergoing in vitro fertilisation (IVF).

Methods:

A total of 122 women with RIF undergoing fresh embryo transfer cycle IVF were randomly allocated to a TEAS or mock TEAS (MTEAS) group. Gonadotrophin therapy using a long protocol was provided in both groups. TEAS consisted of 30 min of stimulation (9–25 mA, 2 Hz) at SP6, CV3, CV4 and Zigong from day 5 of the ovarian stimulation cycle once every other day until the day of embryo transfer. The patients in the control group received MTEAS. Implantation, clinical pregnancy and live birth rates were compared.

Results:

In the TEAS group, the implantation rate, clinical pregnancy rate and live birth rate (24.3%, 32.8% and 27.9%, respectively) were significantly higher than in the MTEAS group (12.1%, 16.4% and 13.1%, respectively).

Conclusions:

TEAS significantly improves the clinical outcomes of subsequent IVF cycles among women who have experienced RIF.

Trial registration number:

ChiCTR-TRC-14004730.

Obstetrical complications of thin endometrium in assisted reproductive technologies: a systematic review

PURPOSE

The aim of the systematic review is to describe the obstetrical complications associated with pregnancies in the context of a thin endometrial lining.

METHODS

Systematic review of the literature.

RESULTS

Patients who conceive in the setting of a thin endometrium have a significantly increased risk of early pregnancy loss, namely miscarriage and ectopic pregnancy. These patients also have a twofold increase in low birth weight and preterm delivery, as well as a significantly higher risk of intrauterine growth restriction and composite adverse perinatal outcomes.

CONCLUSIONS

In addition to the lower probability of conception, a thin endometrium in assisted reproductive technologies appears to be associated with both early and late pregnancy complications. These pregnancies thus warrant special attention and close follow-up from obstetricians.

Effects of menstrual blood‑derived stem cells on endometrial injury repair

The present study aimed to investigate the effects of menstrual blood-derived stem cells (MenSCs) on endometrial injury repair. MenSCs were isolated from human menstrual blood and were cultured in vitro. Flow cytometric analysis of cells in the third generation demonstrated that MenSCs exhibited higher expression levels of cluster of differentiation (CD)90 and lower expression levels of CD146, which suggested that the MenSCs were cultured successfully. A mechanical damage model of unilateral (right) endometrium was established in BALB/c nude mice, which were divided into four groups, Normal, negative control (NC), Model and MenSC. MenSCs transfected with adenovirus-enhanced green fluorescent protein were transplanted into the right uterine cavity of mice in the MenSC and NC groups. The protein expression levels of keratin, vimentin, and vascular endothelial growth factor (VEGF) and the average endometrial thickness were measured by immunohistochemistry; the average optical density of vimentin, VEGF and keratin in the MenSC-treated group was significantly higher compared with the untreated Model group. Fertility tests were performed to determine the pregnancy rate of each group; following endometrial damage in BALB/c nude mice, endometrial thickness was decreased in the Model group, whereas model mice treated with MenSC exhibited increased endometrial thickness and increased the pregnancy rates. Therefore, MenSCs may promote the repair of endometrial lesions in mice by promoting the expression of vimentin, VEGF and keratin.

Decline in Female Fertility After 40 Years

Important factor related to the conception possibility is women age. The decline in fertility with aging is proven and evident in literature. Infertility is increasing and many couples seek help in advanced techniques such as IVF (in vitro fertilization) in order to overcome the problem caused by aging, but the quality of the oocytes is a significant limiting factor. With the aging the quantity and quality of oocytes decreases, such as the quality of the embryo after fertilization. The accelerated rhythm of life, liberty and women inclusion in all kinds of professions brought many benefits to women, but also increasingly postponing births. Each person is unique individual, and can be more or less fertile compared to the average at same age. Unfortunately, some women has a rapid decline in fertility - accelerate aging, very early, already in the early twenties and when testing them with different methods and exams, the result is very low number of oocytes, low value of anti-Müllerian hormone and also very poor quality of these oocytes, or low ovarian reserve. The problem is that when you have accelerate aging, even IVF techniques can not be of great help in achieving pregnancy. The pregnancy rate (17,65%) and the childbirth rate (5,88%) with the patients older than 40 is very low, although comparable to the data from the scientific literature and speaks in favour of the fact that the success of assisted reproductive techniques is very modest with women older than 44.

The impact of endometrial thickness (EMT) on the day of human chorionic gonadotropin (hCG) administration on pregnancy outcomes: a 5-year retrospective cohort analysis in Malaysia

Background

Chances of pregnancy in relation to endometrial thickness (EMT) remain elusive albeit some literatures suggest poorer pregnancy outcomes below the threshold of 6-7 mm, notwithstanding others perceive detrimental effect at thicker EMT. We aim to examine the implication of EMT on pregnancy outcomes using a cut-off of 8 mm and further explore for any effect of ‘thick’ EMT in our patient population.

Methods

This was a retrospective cohort study performed for 162 women to assess the associations between EMT on the human chorionic ganadotropin (hCG) trigger day and pregnancy outcomes in infertile patients undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and autologous fresh embryo transfer (ET) in controlled ovarian stimulation (COS) cycles under an assisted reproductive technology (ART) shared-care programme between public and private institutions from January 2012 through December 2016.

The associations between pregnancy outcomes [Total Pregnancy Rate (TPR), Biochemical Pregnancy Rate (BPR), Clinical Pregnancy Rate (CPR), Ongoing Pregnancy Rate (OPR)/ Live Birth Delivery Rate (LBDR), Miscarriage Rate (MR) and Implantation Rate (IR)] and EMT (< 8 or ≥ 8 mm) on the hCG trigger day were evaluated. Besides, the associations between pregnancies outcomes with EMT ≥ 14 mm and ≥ 8 to < 14 mm were further assessed.

Results

We found that the ≥8 mm group had a higher TPR (55.4% vs 21.4%; p = 0.015) and CPR (52.0% vs 21.4%; p = 0.029). However, the BPR, MR, OPR/ LBDR and IR were not associated with the EMT (p > 0.05). All pregnancy outcomes were comparable for ≥14 mm and ≥ 8 to < 14 mm subgroups.

Conclusions

Our findings suggest that EMT < 8 mm on hCG trigger day could adversely affect TPR and CPR in infertile patients undergoing IVF/ICSI-ET. Besides, we also disprove the notion of reduced chances of pregnancy with EMT ≥ 14 mm. The findings are based on completed cycles which each has demonstrated a triple-line endometrial pattern on the hCG trigger day with fresh autologous ET consisted of high-quality morphological gradings. However, our findings are still preliminary to suggest decision for ET transfer, cycle cancellation or adjunctive therapies. Further studies with larger sample size from this geographical region are required to verify the findings.

Six-month recovery needed after dilation and curettage (D and C) for reproductive outcomes in frozen embryo transfer

In this study, the endometrial developmental and reproductive outcomes of frozen embryo transfers (FETs) which were performed subsequent to miscarriages managed by dilation and curettage (D and C) were investigated. The intracytoplasmic sperm injection (ICSI) blastocyst freeze-all cycles performed between January 2014 and August 2016 were screened for the patients who had undergone their FET (first), miscarriages (>5 < 14 weeks), D and C, and the patients who had undergone their FET (second) (study group; n = 71); and patients who underwent FET (1st), a chemical pregnancy loss (PL) (<5 weeks) and FET (2nd) (reference group; n = 38). The live births (LB; delivery >20 weeks) of FET (2nd) were analysed in two time-interval sub-groups: ≤6 months or >6 months. In the study and reference groups, the median endometrial thickness at the second FET of the ≤6 months sub-groups was found to be significantly reduced. The relative risk for LB was significantly higher (1.65 [0.994-2.723] p = .043) in the >6 months study sub-group, with a lower risk for PL (0.62 [0.268-1.427] p = .329), whereas, there were no significant differences between the reference sub-groups. The management of miscarriage with D and C results in a significant and transient decrease in reproductive function in subsequent FET. Impact Statement What is already known on this subject? Approximately, 15-30% of positive pregnancies in assisted reproductive technology (ART) end in biochemical pregnancy losses (PLs) or miscarriages. Cervical dilation with suction or blunt curettage (D and C), has been the procedure most often used to manage the retained products of conception (RPOC) after miscarriage. Intrauterine surgery has the potential to directly affect reproduction, depending on the endometrial impact. What the results of this study add? The endometrium after D and C surgery may require 6 months to recover normal reproductive function, in terms of both live birth and PL. The extent of the damage to endometrial function is not found to be reflected in the endometrial thickness. What the implications are of these findings for clinical practice and/or further research? Patients who undergo miscarriage after their ART treatment may need to delay further treatment for 6 months to optimise their chances of LB. Alternative miscarriage management procedures need to be investigated; procedures that have lower risks for an adverse reproductive function and allow for shorter time intervals between treatments.

Endometrial thickness on the day of embryo transfer is a poor predictor of IVF treatment outcome

STUDY QUESTION

What is the independent contribution of endometrial thickness (EMT) on day of embryo transfer to achieving an ongoing pregnancy and live birth after IVF treatment?

SUMMARY ANSWER

EMT is a poor predictor of IVF success and has only little independent prognostic value.

WHAT IS KNOWN ALREADY

In a number of previous studies, pregnancy rates have been found to be lower in patients with thin endometrium.

STUDY DESIGN SIZE DUARATION

This is a retrospective analysis of data from two large, randomized phase III studies (conducted in Europe and the USA) comparing s.c. progesterone with vaginal progesterone for luteal phase support. The studies were very similar in design, patient population and outcome, and the study data were combined and analysed on an individual patient level.

PARTICIPANTS/MATERIALS SETTING METHOD

Subjects were infertile patients with an indication for IVF/ICSI, aged between 18 and 42 years, BMI <30 kg/m², <3 prior ART cycles and ≥ 3 oocytes after controlled ovarian stimulation with GnRH-agonist or GnRH-antagonist. EMT was assessed on day of embryo transfer (n = 1401). The association of EMT and ongoing pregnancy rate was determined by comparison of outcomes by quantiles of EMT. The predictive capacity of EMT for ongoing pregnancy achievement was assessed at each millimeter cut-off. Finally, a regression model was built to determine the contribution of EMT among other confounders, such as age and oocyte numbers, on the likelihood of ongoing pregnancy and live birth.

MAIN RESULTS AND THE ROLE OF CHANCE

In univariate analysis, ongoing pregnancy rates correlate to EMT. In patients above a cut-off of ≥9 mm EMT, the chance of pregnancy was higher as compared to patients with an EMT of 3-8 mm (odds ratio (OR) = 1.69, 95% CI: 1.23-2.35, P = 0.001; sensitivity 88.89%, specificity 17.52%, positive predictive value 39.02%, negative predictive value 72.64% and likelihood ratio 1.08). In multivariate regression analysis, after controlling for trial, female age and oocyte numbers, EMT was a statistically significant predictor of live birth (OR = 1.05, 95% CI: 1.00-1.10; P = 0.0351). If EMT indeed is an independent factor affecting outcome, this finding implies that at a baseline live birth rate of 20% an increase of 2 mm in EMT should result in an increase of the live birth rate of ~1.6%.

LIMITATIONS REASONS FOR CAUTION

The independent contribution of EMT to live birth likelihood is small and may result from (undetermined) confounding. The EMT on day of embryo transfer is usually higher as compared to the EMT on day of triggering final oocyte maturation when it is conventionally assessed during routine cycle monitoring. Furthermore, endometrial lining pattern and/or subendometrial Doppler flow have not been assessed and, accordingly, the conclusions of this work are limited to only the thickness of the endometrium.

WIDER IMPLICATIONS OF THE FINDINGS

EMT can be ignored during cycle monitoring of the majority of IVF patients and only the extremes of EMT deserve further diagnostic work-up.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by IBSA. G.G. has received personal fees and non-financial support from MSD, Ferring, Merck-Serono, Finox, TEVA, IBSA, Glycotope, Abbott, Gedeon-Richter as well as personal fees from VitroLife, NMC Healthcare, ReprodWissen, BioSilu and ZIVA. S.T. and B.C. are employees of IBSA.

TRIAL REGISTRATION NUMBER

NCT00827983 and NCT00828191 (clinicaltrials.gov).

Trial registration date

23 January 2009 (NCT00827983 and NCT00828191).

DATE OF FIRST PATIENT’S ENROLMENT

January 2009 (NCT00827983 and NCT00828191).

Effects of different open cryo-carriers on embryo survival and clinical outcome in frozen embryo transfer cycle patients

The purpose of this study was to compare the efficacy of different open cryo-carriers: the CryoloopTM, CryotopTM, and CryoleafTM, in embryo survival and clinical outcome in patients with frozen embryo transfer (FET) cycle. We analyzed the embryo survival rate and clinical outcome in 325 patients of 348 FET cycles vitrified with the CryoloopTM (160 cycles), CryotopTM (105 cycles), or CryoleafTM (83 cycles). No significant differences were observed in embryo survival rate (98.8% vs. 100% vs. 97.7%, p > 0.05), HCG positive rate (58.8% vs. 63.8% vs. 57.8%, p > 0.05), biochemical pregnancy rate (6.9% vs. 11.4% vs. 9.6%, p > 0.05), or implantation rate (33.2% vs. 37.4% vs. 34.1%, p > 0.05) in the three groups respectively. The early abortion rate of the CryoloopTM group was significantly higher than that of the CryotopTM and CryoleafTM group (27.1% vs. 3.6% and 7.5%, p < 0.05). At the same time, the average female age of the CryoloopTM group was significantly older by 1 year than that of the CryotopTM and CryoleafTM group (33.29 ± 4.71 years vs. 31.96 ± 4.27 years and 31.1 ± 4.28 years, p < 0.05). There was no significant difference in take home baby rate (38.1% vs. 46.7% vs. 43.4, p > 0.05) or birth weight among the groups (2893.5 ± 780.8 g vs. 2778.4 ± 710.0 g vs. 2724.5 ± 838.8 g, p > 0.05). No case of neonatal malformation was observed in the present study. Overall, CryotopTM and CryoleafTM were effective for embryo vitrification at both the cleavage and blastocyst stage according to the results of clinical outcome and infant characteristics. However, CryoloopTM led to a decreased positive HCG rate and increased early abortion rate, heightened at the cleavage stage.

ABBREVIATIONS

LN₂: liquid nitrogen; CPA: cryoprotectant; ART: assisted reproductive technology; IVF: in vitro fertilization; ICSI: intracytoplasmic sperm injection; BMI: body mass index; FSH: follicular stimulation hormone; COH: controlled ovarian hyperstimulation; FET: frozen embryo transfer; mm: millimeter; HCG: human chorionic gonadotropin; RCT: randomized clinical trial; NC: natural cycle; AC: artificial cycle; EM: equilibration medium; DMSO: dimethyl sulphoxide; EG: ethylene glycol; VM: vitrification medium; WM: warming medium.