1
|
Ou M, Luo L, Yang Y, Yan N, Yan X, Zhong X, Cheong Y, Li T, Ouyang J, Wang Q. Decrease in peripheral natural killer cell level during early pregnancy predicts live birth among women with unexplained recurrent pregnancy loss: a prospective cohort study. Am J Obstet Gynecol 2024; 230:675.e1-675.e13. [PMID: 37914060 DOI: 10.1016/j.ajog.2023.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/21/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Previous studies have suggested that trophoblast cells inhibit the proliferation of peripheral natural killer cells and that the level of peripheral natural killer cells decrease in the middle and late pregnancy stage among healthy women. The change in peripheral natural killer cell level during early pregnancy and the relationship between the change in peripheral natural killer cell level and pregnancy outcomes among women with unexplained recurrent pregnancy loss have not been sufficiently explored. OBJECTIVE This study aimed to characterize the level of prepregnancy peripheral natural killer cells in comparison with those in early pregnancy among women with unexplained recurrent pregnancy loss and to determine if the change in the level of peripheral natural killer cells from prepregnancy to early pregnancy can predict pregnancy outcomes. STUDY DESIGN In this prospective cohort study, 1758 women with recurrent pregnancy loss were recruited between January 2017 and December 2021 among whom 252 women with unexplained recurrent pregnancy loss had prepregnancy and early pregnancy (4-6 weeks gestation) peripheral natural killer cell measurements. These 252 women were divided into 2 groups, namely those with a lower gestational peripheral natural killer cell level (group 1) when compared with prepregnancy levels and those who did not (group 2). The respective outcomes of these groups in terms of live birth and pregnancy loss were comparatively analyzed using chi-square and Student's t tests. Candidate factors that could influence live birth were selected using the Akaike information criterion. The participates were then randomly divided into training and testing groups. A multivariable logistic regression analysis was performed and a nomogram was created to assess the possibility of live birth. The predictive accuracy was determined by the area under the receiver operating characteristic curve and validated by plotting the predicted probabilities and the observed probabilities. A Hosmer-Lemeshow test was used to assess the goodness of fit. RESULTS When early gestational peripheral natural killer cell levels were compared with prepregnancy peripheral natural killer cell levels, 61.5% (154) of women had a comparatively lower early-gestational peripheral natural killer cell level and 38.9% (98) of women had an increase or no change in the peripheral natural killer cell level. The live birth rate in group 1 was 89.0% (137/154), which was significantly higher than the rate of 49.0% (48/98) in group 2 (P<.001). A decrease in the peripheral natural killer cell level (odds ratio, 1.36; 95% confidence interval, 1.22-1.55; P<.001) and the anti-Muellerian hormone level (odds ratio, 1.41; 95% confidence interval, 1.14-1.81; P=.003) were important predicting factors for a higher live birth rate. Female body mass index (odds ratio, 0.97; 95% confidence interval, 0.82-1.15; P=.763) and parity (odds ratio, 1.61; 95% confidence interval, 0.71-4.12; P=.287) also were predicting factors. Furthermore, the area under the receiver operating characteristic curve of the model to diagnose of live birth was 0.853 with a sensitivity of 81.6% and a specificity of 78.0% using the training data set. And the Hosmer-Lemeshow test showed that the model was a good fit (p=6.068). CONCLUSION We report a comparative decrease in the peripheral natural killer cell levels in early gestation when compared with prepregnancy cell levels in more than 60% of women with unexplained recurrent pregnancy loss at 4 to 6 weeks of gestation. When compared with prepregnancy peripheral natural killer cell levels, a decrease in the peripheral natural killer cell level during early pregnancy might be a useful predictor of the live birth rate among women with unexplained recurrent pregnancy loss.
Collapse
Affiliation(s)
- Miaoxian Ou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Lu Luo
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Yuxin Yang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Niwei Yan
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Xi Yan
- Human Development and Health, Faculty of Medicine, Southampton, United Kingdom
| | - Xue Zhong
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Ying Cheong
- Human Development and Health, Faculty of Medicine, Southampton, United Kingdom; Complete Fertility, Southampton, United Kingdom
| | - Tinchiu Li
- Department of Obstetrics and Gynecology, Chinese University of Hong Kong, Hong Kong, China
| | - Juan Ouyang
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Qiong Wang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China.
| |
Collapse
|
2
|
Peero EK, Banjar S, Khoudja R, Ton-Leclerc S, Beauchamp C, Benoit J, Beltempo M, Dahan MH, Gold P, Kadoch IJ, Jamal W, Laskin C, Mahutte N, Phillips S, Sylvestre C, Reinblatt S, Mazer BD, Buckett W, Genest G. Intravenous immunoglobulin for patients with unexplained recurrent implantation failure: a 6-year single center retrospective review of clinical outcomes. Sci Rep 2024; 14:3876. [PMID: 38365988 PMCID: PMC10873418 DOI: 10.1038/s41598-024-54423-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
The effectiveness of intravenous immunoglobulin (IVIg) for patients with unexplained recurrent implantation failure (uRIF) remains debated. We retrospectively analysed outcomes of uRIF patients treated with IVIg compared to a separate control uRIF cohort within our center (01/2014-12/2021). Primary outcomes included live birth, miscarriage, or transfer failure. We documented IVIg side effects and maternal/fetal outcomes. Logistic regression analysis was used to assess for association of IVIg exposure with outcomes and adjust for confounders. The study included 143 patients, with a 2:1 ratio of controls to patients receiving IVIg treatment. Patient characteristics were similar between groups. There was higher live birth rate (LBR) in patients receiving IVIg (32/49; 65.3%) compared to controls (32/94; 34%); p < 0.001). When stratifying patients into moderate and severe uRIF (respectively 3-4 and [Formula: see text] 5 previous good quality blastocyst transfer failures), only patients with severe uRIF benefited from IVIg (LBR (20/29 (69%) versus 5/25 (20%) for controls, p = 0.0004). In the logistic regression analysis, IVIg was associated with higher odds of live birth (OR 3.64; 95% CI 1.78-7.67; p = 0.0004). There were no serious adverse events with IVIg. IVIg can be considered in well selected patients with [Formula: see text] 5 previous unexplained, high quality blastocyst transfer failures. A randomized controlled trial is needed to confirm these findings.
Collapse
Affiliation(s)
- Einav Kadour Peero
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Bnai-Zion Medical Center, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Shorooq Banjar
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rabea Khoudja
- Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | | | - Coralie Beauchamp
- Ovo Clinic, 8000 Boulevard Decarie, Montréal, QC, H4P 2S4, Canada
- Obstetrics and Gynaecology Department, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1J4, Canada
| | - Joanne Benoit
- Ovo Clinic, 8000 Boulevard Decarie, Montréal, QC, H4P 2S4, Canada
- Obstetrics and Gynaecology Department, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1J4, Canada
| | - Marc Beltempo
- Division of Neonatology, Montreal Children's Hospital - McGill University Health Centre, Montreal, QC, Canada
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, QC, Canada
| | - Phil Gold
- Department of Allergy and Immunology, Montreal General Hospital, 1650 Cedar Ave. A6-123, Montreal, QC, H3G 1A4, Canada
| | - Isaac Jacques Kadoch
- Ovo Clinic, 8000 Boulevard Decarie, Montréal, QC, H4P 2S4, Canada
- Obstetrics and Gynaecology Department, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1J4, Canada
| | - Wael Jamal
- Clinique OVO, 8000 boulevard Décarie, Montréal, QC, H4P 2S4, Canada
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Carl Laskin
- TRIO Fertility, 655 Bay St, Toronto, ON, M5G 2K4, Canada
- Deptartments of Medicine and Obstetrics & Gynecology University of Toronto, 27 King's College Cir, Toronto, ON, M5S, Canada
| | - Neal Mahutte
- The Montreal Fertility Centre, 5252 de Maisonneuve Blvd West, Suite 220, Montreal, QC, H4A 3S5, Canada
| | - Simon Phillips
- Clinique OVO, 8000 boulevard Décarie, Montréal, QC, H4P 2S4, Canada
- Faculty of Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1J4, Canada
| | - Camille Sylvestre
- Ovo Clinic, 8000 Boulevard Decarie, Montréal, QC, H4P 2S4, Canada
- Division of Reproductive Endocrinology and Infertility, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T1J4, Canada
| | - Shauna Reinblatt
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, QC, Canada
- McGill University Health Care Reproductive Center, 888 Boul. De Maisonneuve E# 200, Montreal, QC, H2L 4S8, Canada
| | - Bruce D Mazer
- Department of Pediatrics, Division of Allergy Immunology and Clinical Dermatology, Montreal Children's Hospital, McGill University, Montréal, QC, Canada
- Program in Translational Research in Respiratory Diseases, Research Institute of the McGill, University Health Centre, Montréal, QC, Canada
| | - William Buckett
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, QC, Canada
- McGill University Health Care Reproductive Center, 888 Boul. De Maisonneuve E# 200, Montreal, QC, H2L 4S8, Canada
| | - Genevieve Genest
- Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.
| |
Collapse
|
3
|
Li W, Liu M, Zhou M, Zhou X, Zhang D, Duan J, Zhang A, Xu B. Downregulation of SEPTIN11 inhibits endometrial epithelial cell adhesive function in patients with elevated peripheral blood natural killer cell counts. Reprod Biomed Online 2023; 47:103203. [PMID: 37349244 DOI: 10.1016/j.rbmo.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 03/31/2023]
Abstract
RESEARCH QUESTION What is the underlying mechanism of IVF and embryo transfer (IVF-ET) failure in patients with elevated peripheral blood natural killer cell (pNK) counts? DESIGN Patients undergoing IVF-ET cycles for tubal obstruction or pelvic adhesion (n = 486) were assigned to three groups: high (CD56+CD16+pNK >30% [n = 49]); medium (15< CD56+CD16+pNK ≤30% [n = 211]); and normal pNK groups (5≤ CD56+CD16+pNK ≤15% [n = 226]). Their general condition, previous pregnancy history and IVF outcomes were compared. Uterine fluid and endometrial tissue from patients in the high and normal pNK groups were collected during the mid-secretory phase and studied to elucidate the molecular mechanism underlying impaired endometrial receptivity. RESULTS The highest incidence of IVF-ET cycles (P < 0.0001) and biochemical pregnancy losses (P < 0.0001), and lowest implantation and clinical pregnancy rates (both P < 0.0001), were observed in patients with pNK over 30%. No significant difference was found in the number of previous miscarriages and rate of spontaneous miscarriage in IVF outcomes. Lower Septin11 (SEPT11) expression in the uterine fluid and endometrial epithelial cells (EEC), and higher endometrial IFN-γ, was observed in patients with high pNK. Ishikawa cell and human endometrial epithelial cell (HEEC) adhesion was inhibited after SEPT11 knock-down. Elevated IFN-γ decreased the SEPT11 protein levels in Ishikawa cells and HEECs. CONCLUSIONS CD56+CD16+pNK above 30% may be a threshold for adverse IVF-ET outcomes. Low SEPT11 expression in EEC inhibits cell adhesion, which may cause impaired endometrial receptivity in patients with elevated pNK. The level of SEPT11 in mid-secretory uterine fluid could serve as a non-invasive marker to assess endometrial receptivity in these patients.
Collapse
Affiliation(s)
- Wenzhu Li
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Mengyu Liu
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Mingjuan Zhou
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiaowei Zhou
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dan Zhang
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jingru Duan
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Aijun Zhang
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Bufang Xu
- Department of Obstetrics and Gynecology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Shanghai Key Laboratory of Reproductive Medicine, Department of Histoembryology, Genetics and Developmental Biology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| |
Collapse
|
4
|
Ma N, Li J, Zhang J, Jin Y, Wang J, Qin W, Hang F, Qin A. Combined oral antibiotics and intrauterine perfusion can improve in vitro fertilization and embryo transfer pregnancy outcomes in patients with chronic endometritis and repeated embryo implantation failure. BMC Womens Health 2023; 23:344. [PMID: 37391748 PMCID: PMC10311699 DOI: 10.1186/s12905-023-02443-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/18/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND The aim of this retrospective study was to investigate whether oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone) are beneficial for patients with repeated implantation failure (RIF) and chronic endometritis (CE) to improve clinical pregnancy outcomes. METHODS Patients with RIF and CE were diagnosed using hysteroscopy and histology together. A total of 42 patients were enrolled in the study. All patients received oral antibiotics (doxycycline combined with metronidazole) and 22 patients underwent intrauterine perfusion (gentamicin combined with dexamethasone) immediately after the end of oral antibiotic therapy. Pregnancy outcomes were evaluated during the first in vitro fertilization (IVF) and embryo transfer (ET) cycle. RESULTS For the first D3 ET after treatment with oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone), higher embryo implantation rate (30.95% vs. 26.67%, P = 0.0308), clinical pregnancy rate (30% vs. 50%, P < 0.001), live birth rate (33.33% vs. 45.45%, P < 0.0001). No fetal malformations or ectopic pregnancies were observed. CONCLUSION We report oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone) as a novel treatment for CE to improve the outcomes of successful pregnancy compared with those of oral antibiotics alone.
Collapse
Affiliation(s)
- Nana Ma
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiaxu Li
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Junlei Zhang
- Department of Sports Medicine, Southern University of Science And Technology Hospital, Shenzhen, China
| | - Yufu Jin
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiawei Wang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Weili Qin
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Fu Hang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
| | - Aiping Qin
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
| |
Collapse
|
5
|
Cimadomo D, de los Santos MJ, Griesinger G, Lainas G, Le Clef N, McLernon DJ, Montjean D, Toth B, Vermeulen N, Macklon N. ESHRE good practice recommendations on recurrent implantation failure. Hum Reprod Open 2023; 2023:hoad023. [PMID: 37332387 PMCID: PMC10270320 DOI: 10.1093/hropen/hoad023] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 06/20/2023] Open
Abstract
STUDY QUESTION How should recurrent implantation failure (RIF) in patients undergoing ART be defined and managed? SUMMARY ANSWER This is the first ESHRE good practice recommendations paper providing a definition for RIF together with recommendations on how to investigate causes and contributing factors, and how to improve the chances of a pregnancy. WHAT IS KNOWN ALREADY RIF is a challenge in the ART clinic, with a multitude of investigations and interventions offered and applied in clinical practice, often without biological rationale or with unequivocal evidence of benefit. STUDY DESIGN SIZE DURATION This document was developed according to a predefined methodology for ESHRE good practice recommendations. Recommendations are supported by data from the literature, if available, and the results of a previously published survey on clinical practice in RIF and the expertise of the working group. A literature search was performed in PubMed and Cochrane focussing on 'recurrent reproductive failure', 'recurrent implantation failure', and 'repeated implantation failure'. PARTICIPANTS/MATERIALS SETTING METHODS The ESHRE Working Group on Recurrent Implantation Failure included eight members representing the ESHRE Special Interest Groups for Implantation and Early Pregnancy, Reproductive Endocrinology, and Embryology, with an independent chair and an expert in statistics. The recommendations for clinical practice were formulated based on the expert opinion of the working group, while taking into consideration the published data and results of the survey on uptake in clinical practice. The draft document was then open to ESHRE members for online peer review and was revised in light of the comments received. MAIN RESULTS AND THE ROLE OF CHANCE The working group recommends considering RIF as a secondary phenomenon of ART, as it can only be observed in patients undergoing IVF, and that the following description of RIF be adopted: 'RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions'. It was agreed that the recommended threshold for the cumulative predicted chance of implantation to identify RIF for the purposes of initiating further investigation is 60%. When a couple have not had a successful implantation by a certain number of embryo transfers and the cumulative predicted chance of implantation associated with that number is greater than 60%, then they should be counselled on further investigation and/or treatment options. This term defines clinical RIF for which further actions should be considered. Nineteen recommendations were formulated on investigations when RIF is suspected, and 13 on interventions. Recommendations were colour-coded based on whether the investigations/interventions were recommended (green), to be considered (orange), or not recommended, i.e. not to be offered routinely (red). LIMITATIONS REASONS FOR CAUTION While awaiting the results of further studies and trials, the ESHRE Working Group on Recurrent Implantation Failure recommends identifying RIF based on the chance of successful implantation for the individual patient or couple and to restrict investigations and treatments to those supported by a clear rationale and data indicating their likely benefit. WIDER IMPLICATIONS OF THE FINDINGS This article provides not only good practice advice but also highlights the investigations and interventions that need further research. This research, when well-conducted, will be key to making progress in the clinical management of RIF. STUDY FUNDING/COMPETING INTERESTS The meetings and technical support for this project were funded by ESHRE. N.M. declared consulting fees from ArtPRED (The Netherlands) and Freya Biosciences (Denmark); Honoraria for lectures from Gedeon Richter, Merck, Abbott, and IBSA; being co-founder of Verso Biosense. He is Co-Chief Editor of Reproductive Biomedicine Online (RBMO). D.C. declared being an Associate Editor of Human Reproduction Update, and declared honoraria for lectures from Merck, Organon, IBSA, and Fairtility; support for attending meetings from Cooper Surgical, Fujifilm Irvine Scientific. G.G. declared that he or his institution received financial or non-financial support for research, lectures, workshops, advisory roles, or travelling from Ferring, Merck, Gedeon-Richter, PregLem, Abbott, Vifor, Organon, MSD, Coopersurgical, ObsEVA, and ReprodWissen. He is an Editor of the journals Archives of Obstetrics and Gynecology and Reproductive Biomedicine Online, and Editor in Chief of Journal Gynäkologische Endokrinologie. He is involved in guideline developments and quality control on national and international level. G.L. declared he or his institution received honoraria for lectures from Merck, Ferring, Vianex/Organon, and MSD. He is an Associate Editor of Human Reproduction Update, immediate past Coordinator of Special Interest Group for Reproductive Endocrinology of ESHRE and has been involved in Guideline Development Groups of ESHRE and national fertility authorities. D.J.M. declared being an Associate Editor for Human Reproduction Open and statistical Advisor for Reproductive Biomedicine Online. B.T. declared being shareholder of Reprognostics and she or her institution received financial or non-financial support for research, clinical trials, lectures, workshops, advisory roles or travelling from support for attending meetings from Ferring, MSD, Exeltis, Merck Serono, Bayer, Teva, Theramex and Novartis, Astropharm, Ferring. The other authors had nothing to disclose. DISCLAIMER This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation. ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type. Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.
Collapse
Affiliation(s)
| | - D Cimadomo
- IVIRMA Global Research Alliance, GENERA, Clinica Valle Giulia, Rome, Italy
| | | | - G Griesinger
- Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
- University of Luebeck, Luebeck, Germany
| | - G Lainas
- Eugonia IVF, Unit of Human Reproduction, Athens, Greece
| | - N Le Clef
- ESHRE Central Office, Strombeek-Bever, Belgium
| | - D J McLernon
- School of Medicine Medical Sciences and Nutrition, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - D Montjean
- Fertilys Fertility Centers, Laval & Brossard, Canada
| | - B Toth
- Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - N Vermeulen
- ESHRE Central Office, Strombeek-Bever, Belgium
| | - N Macklon
- Correspondence address. ESHRE Central Office, BXL7—Building 1, Nijverheidslaan 3, B-1853 Strombeek-Bever, Belgium. E-mail:
| |
Collapse
|
6
|
Stope MB, Mustea A, Sänger N, Einenkel R. Immune Cell Functionality during Decidualization and Potential Clinical Application. Life (Basel) 2023; 13:life13051097. [PMID: 37240742 DOI: 10.3390/life13051097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Due to a vast influx in the secretory phase of the menstrual cycle, leukocytes represent 40-50% of the decidua at the time of implantation. Their importance for the implantation, maintenance of pregnancy, and parturition are known yet not fully understood. Thus, in idiopathic infertility, decidual immune-related factors are speculated to be the cause. In this review, the immune cell functions in the decidua were summarized, and clinical diagnostics, as well as interventions, were discussed. There is a rising number of commercially available diagnostic tools. However, the intervention options are still limited and/or poorly studied. In order for us to make big steps towards the proper use of reproductive immunology findings, we need to understand the mechanisms and especially support translational research.
Collapse
Affiliation(s)
- Matthias B Stope
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Nicole Sänger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Rebekka Einenkel
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Bonn, 53127 Bonn, Germany
| |
Collapse
|
7
|
Duan Y, Liu Y, Xu Y, Zhou C. Bioinformatics Analysis Identifies Key Genes in Recurrent Implantation Failure Based on Immune Infiltration. Reprod Sci 2023; 30:952-965. [PMID: 36045247 DOI: 10.1007/s43032-022-01060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022]
Abstract
Recurrent implantation failure (RIF) is a thorny problem often encountered in the field of assisted reproduction. Existing evidences suggest that immune dysregulation may be involved in the pathogenesis of RIF. The purpose of this study is to explore immune-related genes contributing to RIF through data mining. The endometrial expression profiles of 24 RIF and 24 controls were obtained from the GEO database. The immune infiltration in bulk tissue was estimated by single sample gene set enrichment analysis (ssGSEA) method based on marker gene sets for immune cells generated from endometrial single-cell RNA sequencing data. The results showed that the infiltration levels of B cells and regulatory T cells (Tregs) were significantly reduced in the RIF group. Four hub genes (GJA1, PRKAG2, CPT1A, and ICA1) were identified by integrated analysis of weighted gene co-expression network analysis (WGCNA), random forest and LASSO regression. Moreover, these hub genes were significantly correlated with certain immune-related factors, especially CXCL12, CEACAM1, and XCR1. Single-gene GSEA indicated that the pathways associated with hub genes included the regulation of cell cycle, the process of epithelial-mesenchymal transition and transplant rejection, etc. A predictive model for RIF was constructed based on hub genes and performed well in the training dataset and the other two external datasets. Thus, this study identified immune-related key genes in RIF and provided new biomarkers for early diagnosis.
Collapse
Affiliation(s)
- Yuwei Duan
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, Guangdong, China
| | - Yongxiang Liu
- Department of Reproductive Medicine, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - Yanwen Xu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, Guangdong, China
| | - Canquan Zhou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, Guangdong, China.
| |
Collapse
|
8
|
Mukherjee N, Sharma R, Modi D. Immune alterations in recurrent implantation failure. Am J Reprod Immunol 2023; 89:e13563. [PMID: 35587052 DOI: 10.1111/aji.13563] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/01/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
A failure to achieve pregnancy after three or more embryo transfer cycles with high-quality blastocysts is referred to as recurrent implantation failure (RIF). RIF can be due to altered uterine factors or male factors or embryo factors. Disrupted endometrial receptivity, altered expression of genes in several pathways, immunologic disturbances in the peripheral blood and/or the endometrium, and epigenetic alterations are associated with RIF. Amongst the immunologic disturbances, altered Th1/Th2 ratio, altered NK cell and macrophage numbers are observed in women with RIF. However, not all women with RIF have the same kind of immune dysfunction suggesting that RIF is a heterogeneous condition associated with varied immune responses and one size may not fit all. Thus, personalized therapies based on the immune status of the patient are being tested in women with RIF. In general, women with a high Th1/Th2 ratio are offered Tacrolimus, while intravenous IgG is recommended in women with high NK cell numbers/HLA mismatch. Women with hyperactivated immune status in the uterus are offered progesterone support, prednisolone, vitamin E, and intralipid treatment to suppress inflammation and oxidative stress, while endometrial scratching and intrauterine hCG administration are offered to women with hypo-active immune status. There is a need for standardized tests for evaluation of immune status in patients and sufficiently powered randomized controlled trials for personalized therapies to determine which of these will be beneficial in women with RIF. Till then, the ART community should limit the use of such add-on interventions in women with RIF.
Collapse
Affiliation(s)
- Nupur Mukherjee
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
| | - Richa Sharma
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
| | - Deepak Modi
- Molecular and Cellular Biology Laboratory, ICMR-National Institute for Research in Reproductive and Child Health, Indian Council of Medical Research (ICMR), Parel, Mumbai, Maharashtra, India
| |
Collapse
|
9
|
Liu M, Yuan Y, Qiao Y, Tang Y, Sui X, Yin P, Yang D. The effectiveness of immunomodulatory therapies for patients with repeated implantation failure: a systematic review and network meta-analysis. Sci Rep 2022; 12:18434. [PMID: 36319652 PMCID: PMC9626579 DOI: 10.1038/s41598-022-21014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 09/21/2022] [Indexed: 11/23/2022] Open
Abstract
This meta-analysis analyzed the clinical pregnancy outcomes of repeated implantation failure (RIF) patients treated with immunomodulatory therapies. Publications (published by August 16, 2021) were identified by searching the PubMed, Embase, and Web of Science databases. The quality of the studies was evaluated with the Cochrane bias risk assessment tool, and a network meta-analysis was performed with Stata 14.0. The outcomes were clinical pregnancy rate (CPR), live birth rate (LBR), and implantation rate (IR). The results of our network meta-analysis of 16 RCTs (including 2,008 participants) show that PBMCs, PRP, and SC-GCSF can significantly improve the CPR compared with LMWH (PBMCs: OR 2.15; 95% CI 1.21-3.83; PRP: OR 2.38; 95% CI 1.08-5.24; SC-GCSF: OR 2.46; 95% CI 1.05-5.72). The LBR of PRP was significantly higher than those of IU-GCSF (OR 3.81; 95% CI 1.22-11.86), LMWH (OR 4.38; 95% CI 1.50-12.90), and intralipid (OR 3.85; 95% CI 1.03-14.29), and the LBR of PBMCs was also significantly better than that of LMWH (OR 2.35; 95% CI 1.14-4.85). Furthermore, PRP treatment significantly improved the IR compared with LMWH treatment (OR 2.81; 95% CI 1.07-7.4). The limited evidence from existing RCTs suggests that PBMCs and PRP are the best therapeutic options for RIF patients. However, owing to the quantity limitation, more top-quality research is required to obtain additional high-level evidence.
Collapse
Affiliation(s)
- Mengqi Liu
- Kapok Zhucheng Medical Clinic, No. 302, No. 9, Huaqiang Road, Tianhe District, Guangzhou, 510623 China
| | - Yuan Yuan
- Kapok Zhucheng Medical Clinic, No. 302, No. 9, Huaqiang Road, Tianhe District, Guangzhou, 510623 China
| | - Yan Qiao
- Kapok Zhucheng Medical Clinic, No. 302, No. 9, Huaqiang Road, Tianhe District, Guangzhou, 510623 China
| | - Yuzhu Tang
- Shanghai Kapok Integrated Traditional Chinese and Western Medicine Clinic Co., Ltd., 3rd Floor, No. 21 Pudong South Road, Pudong New Area, Shanghai, 200126 China
| | - Xi Sui
- Shenzhen Kapok Health Medical Co., Ltd. Kapok Clinic, L2-12, Shenye Tairan Building, Tairan 8th Road, Shatou Street, Futian District, Shenzhen, 518042 China
| | - Ping Yin
- Guangzhou Kapok Medical Investment Co., Ltd., Room 116 and 117, No. 173, South 2nd Road, Yuncheng, Baiyun District, Guangzhou, 510405 China
| | - Dongzi Yang
- grid.12981.330000 0001 2360 039XDepartment of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou City, 528406 Guangdong Province China
| |
Collapse
|
10
|
Benkhalifa M, Joao F, Duval C, Montjean D, Bouricha M, Cabry R, Bélanger MC, Bahri H, Miron P, Benkhalifa M. Endometrium Immunomodulation to Prevent Recurrent Implantation Failure in Assisted Reproductive Technology. Int J Mol Sci 2022; 23:ijms232112787. [PMID: 36361577 PMCID: PMC9654171 DOI: 10.3390/ijms232112787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 12/02/2022] Open
Abstract
After more than four decades of assisted reproductive technology (ART) practice worldwide, today more than 60% of women undergoing in vitro fertilization (IVF) treatments fail to become pregnant after the first embryo transfer and nearly 20% of patients are suffering from unexplained recurrent implantation failures (RIFs) and repeated pregnancy loss (RPL). The literature reported different causes of RIF–RPL, mainly multifactorial, endometrial and idiopathic. RIF remains a black box because of the complicated categorization and causes of this physio-pathological dysregulation of implantation and pregnancy process after ovarian stimulation. Many options were suggested as solutions to treat RIF–RPL with controversial results on their usefulness. In this article, we reviewed different possible therapeutic options to improve implantation rates and clinical outcomes. Based on our experience we believe that endometrium immunomodulation after intrauterine insemination of activated autologous peripheral blood mononuclear cells (PBMCs) or platelet-rich plasma (PRP) can be a promising therapeutic solution. On the other hand, peripheral lymphocyte balance typing, specific cytokines and interleukins profiling can be proposed as predictive biomarkers of implantation before embryo transfer.
Collapse
Affiliation(s)
- Mustapha Benkhalifa
- HB Laboratory, Tunis TN 1007, Tunisia
- Faculty of Sciences of Bizerte, University of Carthage, Bizerte TN 7021, Tunisia
| | - Fabien Joao
- Fertilys Reproductive Center, Laval, QC H7S 1Z5, Canada
| | - Cynthia Duval
- Fertilys Reproductive Center, Laval, QC H7S 1Z5, Canada
| | | | - Molka Bouricha
- Department of Reproductive Medicine, Reproductive Biology & Genetics, University Hospital and School of Medicine Picardie University Jules Verne, 80054 Amiens, France
| | - Rosalie Cabry
- Department of Reproductive Medicine, Reproductive Biology & Genetics, University Hospital and School of Medicine Picardie University Jules Verne, 80054 Amiens, France
| | | | | | - Pierre Miron
- Fertilys Reproductive Center, Laval, QC H7S 1Z5, Canada
| | - Moncef Benkhalifa
- Department of Reproductive Medicine, Reproductive Biology & Genetics, University Hospital and School of Medicine Picardie University Jules Verne, 80054 Amiens, France
- PeriTox Laboratory, CURS, Amiens Sud, 80480 Salouël, France
- Correspondence: ; Tel.: +33-677-867-390
| |
Collapse
|
11
|
Evidence for the effectiveness of immunologic therapies in women with subfertility and/or undergoing assisted reproduction. Fertil Steril 2022; 117:1144-1159. [PMID: 35618357 DOI: 10.1016/j.fertnstert.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/23/2023]
Abstract
Implantation is a critical step in the establishment of a successful pregnancy, depending on a complex immune-endocrine dialogue between the developing embryo and maternal endometrium. Research suggests that altered immunity in the maternal decidua results in implantation impairment and failure. Immunomodulatory drugs have, thus, been widely used in assisted conception to aid embryo implantation, despite an absence of consensus on their effectiveness and safety. We conducted a systematic review and meta-analysis of interventional studies investigating the use of immunomodulators in women undergoing assisted reproduction. Evidence was uncertain of an effect for most of the included interventions, owing to heterogeneous findings and a paucity of high-quality studies. For certain patient subgroups, however, the use of specific immunomodulatory therapies may offer some benefit. There is a need for further large randomized controlled trials to corroborate these findings.
Collapse
|
12
|
Turocy J, Williams Z. Novel therapeutic options for treatment of recurrent implantation failure. Fertil Steril 2021; 116:1449-1454. [PMID: 34836580 DOI: 10.1016/j.fertnstert.2021.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
Despite the challenges in studying recurrent implantation failure, progress is currently being made in therapeutic options to help those who suffer from recurrent implantation failure. Three of the most promising therapeutic options for recurrent implantation failure include immune therapies such as peripheral blood mononuclear cells, platelet rich plasma and subcutaneous granulocyte-colony stimulating factor.
Collapse
Affiliation(s)
- Jenna Turocy
- Columbia University Fertility Center, New York, New York
| | - Zev Williams
- Columbia University Fertility Center, New York, New York.
| |
Collapse
|
13
|
Efficacy of therapies and interventions for repeated embryo implantation failure: a systematic review and meta-analysis. Sci Rep 2021; 11:1747. [PMID: 33462292 PMCID: PMC7814130 DOI: 10.1038/s41598-021-81439-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/21/2020] [Indexed: 01/29/2023] Open
Abstract
The aim of the present systematic review and meta-analysis was to assess the effect of the different therapeutic options for repeated embryo implantation failure (RIF) on a subsequent IVF cycle outcome. Twenty-two RCTs and nineteen observational studies were included. Pooling of results showed a beneficial effect of intrauterine PBMC infusion on both CPR (RR 2.18; 95% CI 1.58-3.00; p < 0.00001; OR 2.03; 95% CI 1.22-3.36; p = 0.006) and LBR (RR 2.41; 95% CI 1.40-4.16; p = 0.002; OR 3.73; 95% CI 1.13-12.29; p = 0.03), of subcutaneous G-CSF administration on CPR (RR 2.29; 95% CI 1.58-3.31; p < 0.0001) and of intrauterine PRP infusion on CPR (RR 2.45; 95% CI 1.55-3.86; p = 0.0001). Observational studies also demonstrated a positive effect of IVIG and intrauterine hCG infusion on both CPR and LBR and of atosiban on CPR. Studies investigating intrauterine G-CSF infusion, LMWH, intravenous intralipid, hysteroscopy, blastocyst-stage ET, ZIFT, PGT-A and AH failed to observe an impact on IVF outcome. The quality of the evidence that emerged from RCTs focused on intrauterine PBMC infusion and subcutaneous G-CSF administration was moderate. For all other therapies/interventions it varied from low to very low. In conclusion, intrauterine PBMC infusion and subcutaneous G-CSF administration are the most promising therapeutic options for RIF. However, further well conducted RCTs are necessary before their introduction into clinical practice.
Collapse
|