Progestogens in the prevention of miscarriage

A review of the optimization of thyroid function, thrombophilia, immunity and uterine milieu treatment strategy for recurrent implantation failure and recurrent pregnancy loss

Background

Aside from embryonic factors, various factors can intricately interfere with embryo implantation and maintenance of pregnancy, causing recurrent implantation failure (RIF) or recurrent pregnancy loss (RPL). This review focuses the optimization of thyroid function, thrombophilia, immunity, and uterine milieu (OPTIMUM) treatment strategy on RIF and RPL.

Methods

Three studies employing the OPTIMUM treatment strategy for patients with RIF and/or RPL were reviewed.

Results

The OPTIMUM improved pregnancy rates in women with RIF aged <40 years. Among advanced age women, however, no significant differences in pregnancy rates were observed between the control, OPTIMUM, and preimplantation genetic testing for aneuploidy (PGT-A) groups, although pregnancy rates were highest after OPTIMUM + PGT-A. The OPTIMUM reduced miscarriage rates in women with RPL aged <40 years. Among advanced age women, PGT-A, but not the OPTIMUM, contributed to miscarriage prevention. Factors predicting pregnancy success in women with RIF who received the OPTIMUM included thrombophilia and young age. Risk factors for an unsuccessful live birth among women with RPL who received the OPTIMUM included advanced age, infertility, diminished ovarian reserve, and non-ART treatment.

Conclusions

The OPTIMUM can improve pregnancy outcomes in women with RIF/RPL, except for advanced age women with embryonic factor-induced reproductive failure.

Therapeutic efficacy of the optimization of thyroid function, thrombophilia, immunity and uterine milieu (OPTIMUM) treatment strategy on pregnancy outcomes after single euploid blastocyst transfer in advanced age women with recurrent reproductive failure

Purpose

To clarify the efficacy of the OPtimization of Thyroid function, Thrombophilia, IMmunity and Uterine Milieu (OPTIMUM) treatment strategy on pregnancy outcomes after euploid blastocyst transfer in advanced age women with recurrent implantation failure (RIF) and/or recurrent pregnancy loss (RPL).

Methods

Between January 2019 and May 2022, 193 consecutive women aged ≥40 years with RIF and/or RPL received single euploid blastocyst transfer. Before embryo transfer, 127 women underwent RIF/RPL testing. Chronic endometritis was treated with mainly antibiotics, aberrant high Th1/Th2 cell ratios with vitamin D and/or tacrolimus, overt/subclinical hypothyroidism with levothyroxine, and thrombophilia with low-dose aspirin. We compared pregnancy outcomes in the women who did and did not receive the OPTIMUM treatment strategy.

Results

Women with RIF/RPL in the OPTIMUM group had significantly higher clinical pregnancy and livebirth rates than did those in the control group (clinical pregnancy rate of 71.7% and 45.5%, p < 0.001; livebirth rate of 64.6% and 39.4%, p = 0.001, respectively). However, preimplantation genetic testing for aneuploidy with and without OPTIMUM promoted low miscarriage rates with no significant difference between them (9.9%, and 13.3%, respectively; p = 0.73).

Conclusions

The OPTIMUM treatment strategy improved clinical pregnancy rates after single euploid blastocyst transfer; but not miscarriage rates.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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