Comparison between findings of saline infusion sonohysterography and office hysteroscopy in patients with recurrent implantation failure

ESHRE good practice recommendations on recurrent implantation failure

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.

Diagnostic Performance of Two-Dimensional Ultrasound, Two-Dimensional Sonohysterography and Three-Dimensional Ultrasound in the Diagnosis of Septate Uterus-A Systematic Review and Meta-Analysis

BACKGROUND

The septate uterus is the most common congenital uterine anomaly, and hysteroscopy is the gold standard for diagnosing it. The goal of this meta-analysis is to perform a pooled analysis of the diagnostic performance of two-dimensional transvaginal ultrasonography, two-dimensional transvaginal sonohysterography, three-dimensional transvaginal ultrasound, and three-dimensional transvaginal sonohysterography for the diagnosis of the septate uterus.

METHODS

Studies published between 1990 and 2022 were searched in PubMed, Scopus, and Web of Science. From 897 citations, we selected eighteen studies to include in this meta-analysis.

RESULTS

The mean prevalence of uterine septum in this meta-analysis was 27.8%. Pooled sensitivity and specificity were 83% and 99% for two-dimensional transvaginal ultrasonography (ten studies), 94% and 100% for two-dimensional transvaginal sonohysterography (eight studies), and 98% and 100% for three-dimensional transvaginal ultrasound (seven articles), respectively. The diagnostic accuracy of three-dimensional transvaginal sonohysterography was only described in two studies, and we did not calculate the pooled sensitivity and specificity for this method.

CONCLUSION

Three-dimensional transvaginal ultrasound has the best performance capacity for the diagnosis of the septate uterus.

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial

PURPOSE

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures.

METHODS

This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure.

RESULTS

Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01).

CONCLUSION

Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04415489.

Recurrent implantation failure in IVF: A Canadian Fertility and Andrology Society Clinical Practice Guideline

Recurrent implantation failure (RIF) after IVF is a challenging topic for clinicians and can be a devastating reality for some patients with infertility. The purpose of this guideline from the Canadian Fertility and Andrology Society (CFAS) is to provide the most relevant evidence to date for the assessment and management of RIF. This guideline was developed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. This guideline recognizes the presence of heterogeneity in the definition of RIF. Recommendations are offered here on the investigation of RIF and management options that may increase the chance of a live birth.

Fertility outcome after saline sonography guided removal of intrauterine polyps in women with unexplained infertility

Objective: To assess the effect of removal of unsuspected polyps as delineated on saline sonography on the clinical pregnancy rate in women with unexplained infertility. Methodology: A prospective case control study was being conducted from 1st October 2016 to 30^th September 2018 at Aziz Medical Centre, Karachi. Women diagnosed with unexplained infertility and unsuspected polyps revealed on saline sonography were included as cases (Group A). They were offered removal of polyps under ultrasound guidance and general anesthesia. Saline sonography was repeated at the time to ensure complete removal (Izhar's Modification). Those with unsuspected polyps on saline sonography, but who refused the intervention, were classified as controls (Group B). Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heartbeat present on transvaginal scan during the follow up period. Results: During the study period, out of 92 cases, 37 (40.2%) conceived and out of 92 controls, 10 (10.9%) conceived, which proved that polypectomy increased the chances of conception four-fold (p <0.001). The mean time to conception was also significantly lower for cases than controls (9.26 ± 3.928 months vs. 11.33 ± 2.07 months, p <0.001). The cumulative pregnancy rate was significantly higher in the polypectomy group (log-rank test, p <0.001). The duration of infertility (p = 0.007), position of polyp (p = 0.049) and polypectomy (p <0.001) influenced pregnancy rate. Conclusions: Our study shows the beneficial effect of removal of polyps. Women are four times more likely to conceive spontaneously after polypectomy.

Objective: To assess the effect of removal of unsuspected polyps as delineated on saline sonography on the clinical pregnancy rate in women with unexplained infertility. Methodology: A prospective case control study was being conducted from 1st October 2016 to 30^th September 2018 at Aziz Medical Centre, Karachi. Women diagnosed with unexplained infertility and unsuspected polyps revealed on saline sonography were included as cases (Group A). They were offered removal of polyps under ultrasound guidance and general anesthesia. Saline sonography was repeated at the time to ensure complete removal (Izhar’s Modification). Those with unsuspected polyps on saline sonography, but who refused the intervention, were classified as controls (Group B). Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heartbeat present on transvaginal scan during the follow up period. Results: During the study period, out of 92 cases, 37 (40.2%) conceived and out of 92 controls, 10 (10.9%) conceived, which proved that polypectomy increased the chances of conception four-fold (p <0.001). The mean time to conception was also significantly lower for cases than controls (9.26 ± 3.928 months vs. 11.33 ± 2.07 months, p <0.001). The cumulative pregnancy rate was significantly higher in the polypectomy group (log-rank test, p <0.001). The duration of infertility (p = 0.007), position of polyp (p = 0.049) and polypectomy (p <0.001) influenced pregnancy rate. Conclusions: Our study shows the beneficial effect of removal of polyps. Women are four times more likely to conceive spontaneously after polypectomy.

Association Between miR-605A>G, miR-608G>C, miR-631I>D, miR-938C>T, and miR-1302-3C>T Polymorphisms and Risk of Recurrent Implantation Failure

Recurrent implantation failure (RIF) is diagnosed when pregnancy failure occurs after 2 consecutive in vitro fertilization-embryo transfers (IVF-ET) to the endometrium using at least 4 high-quality embryos. MicroRNAs (miRNAs) are a class of small noncoding RNA and reported to play an important role in cell proliferation as well as implantation process. Recently, it has been reported that miRNA can regulate RIF occurrence. So, we were to examine the association between the specific miRNA polymorphisms and RIF in Korean women. Genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay to determine the frequency of the following polymorphisms: miR-605A>G, miR-608G>C, miR-631I>D, miR-938C>T, and miR-1302-3C>T. Our results demonstrate a decreased incidence of RIF in patients with the miR-1302-3C>T polymorphism (adjusted odds ratio [AOR], 0.234; 95% confidence interval [CI], 0.089-0.618; P = .003). Based on our allele combination analysis, the C-T ( miR-938/ miR-1302-3: OR = 0.259; 95% CI, 0.100-0.674; P = .003) allele was also associated with decreased RIF risk. From our interaction analysis with miR-1302-3, the miR-1302-3CC genotype (AOR = 43.332; 95% CI, 5.576-336.745) showed an association with RIF prevalence in participants with an activated partial thromboplastin time (aPTT) ≤22.6. We found that the miR-1302-3C>T polymorphism is significantly associated with RIF development in Korean women. Specifically, our study suggests that the T allele of miR-1302-3 may decrease the risk of RIF in Korean women.

Establishing patterns on hysteroscopy in abnormal uterine bleeding (AUB)

Introduction:

Pattern recognition of various phases of normal endometrium and endometrial pathologies during hysteroscopy has many advantages. It would help to triage women with AUB, so as to be selective with biopsies and curettages. Recognition of normal variant or benign lesion would reduce burden to the pathologist by decreasing the number of unnecessary sampling. It will also decreases anxiety of the patient as the report/prognostication can be instant in many cases.

Material and methods:

This prospective, double blind, correlation study was carried out in the teaching hospital with a sample population of 70 women presenting with AUB who underwent hysteroscopy and endometrial sampling. We identified patterns of endometrium which can used to predict six endometrial pathologies which were later correlated with the final histological diagnosis.

Results:

There was good correlation between hysteroscopic patterns and histopathology report, 33% of starry sky appearance correlated with atrophic endometrium, 87% of tongue shaped projections correlated with endometrial polyp, 44.4% of pebble stone appearance correlated with myomatous polyp, 50% of polypoidal pattern correlated with endometrial hyperplasia. 100% correlation was seen in strawberry appearance, pattern for secretory endometrium and cerebroid appearance which was pattern designated to endometrial carcinoma.

Conclusion:

Hysteroscopic pattern recognition is a useful concept to triage women who require sampling for histopathological diagnosis.