Mixed double-embryo transfer: A promising approach for patients with repeated implantation failure

Effects of Variable Embryo Transfer on the Variable Window of Implantation and Analysis of Pregnancy Outcomes

Background A descriptive analysis of patients who underwent various embryo transfer methods to address the root cause of their infertility at a tertiary infertility care complex in Wardha, India, is presented herein. This analysis aims to evaluate the management of infertility and assess pregnancy outcomes. Methodology We conducted a retrospective cohort study on patients who underwent various embryo transfer methods to address the cause of their infertility, specifically focusing on a variable window of implantation (WOI) at a tertiary infertility clinic over a one-year period. The medical records of 11 patients in both the variable embryo transfer (VET) and control groups were reviewed and analyzed for this article. Results The examination of medical records revealed a significant improvement in the rate of implantation (p-value = 0.04) and clinical pregnancy outcomes (p-value = 0.03) among patients who underwent VET. Comparable statistical outcomes were observed for other variables of pregnancy outcome, including miscarriage rate, multiple pregnancy rate, and biochemical pregnancy rate. Conclusion This retrospective cohort study suggests that the utilization of VET could be a viable option for women experiencing recurrent implantation failure cycles, particularly when an adequate number of embryos are available. This is owing to the challenges in clinically diagnosing a variable WOI. Further studies with a significantly larger sample population are recommended to validate the results and integrate this approach into the standard operating procedures, aiming to enhance the likelihood of pregnancy in these populations.

Sequential embryo transfer combined with intrauterine perfusion improved pregnancy outcomes in patients with recurrent implantation failure

OBJECTIVE

To compare the application of sequential embryo transfer, cleavage embryo transfer, and blastocyst transfer combined with intrauterine perfusion in frozen-thawed embryo transfer cycles in patients with recurrent implantation failure to provide a reference for reproductive clinicians.

METHODS

The 166 patients who underwent frozen-thawed embryo transfer due to recurrent implantation failure in the reproductive center from January 2021 to March 2022 were retrospectively analyzed. According to the different embryos transferred, they were divided into cleavage embryo transfer groups (72 cases in Group A), blastocyst transfer group (29 cases in Group B), and sequential transfer group (65 cases in Group C). All three groups were treated with intrauterine perfusion 5 days before embryo transfer. The general data and clinical pregnancy outcome indicators, such as embryo implantation rate, clinical pregnancy rate, ongoing pregnancy rate, live birth rate, twin rate, were compared among the three groups.

RESULTS

The embryo implantation rate (53.1%), clinical pregnancy rate (76.9%), ongoing pregnancy rate (67.7%) and live birth rate(66.15%) in the sequential transfer group were significantly higher than those in the other two groups (P < 0.05), and the ectopic pregnancy rate was lower in the sequential transfer group.

CONCLUSION

Sequential transfer combined with intrauterine perfusion partially improves clinical pregnancy outcomes and reduces the risk of ectopic pregnancy in frozen embryo cycle transfers in patients with recurrent implantation failure, which may be a favourable transfer reference strategy for patients with recurrent implantation failure.

Embryo Transfer Strategies for Women with Recurrent Implantation Failure During the Frozen-thawed Embryo Transfer Cycles: Sequential Embryo Transfer or Double-blastocyst Transfer?

OBJECTIVE

Both sequential embryo transfer (SeET) and double-blastocyst transfer (DBT) can serve as embryo transfer strategies for women with recurrent implantation failure (RIF). This study aims to compare the effects of SeET and DBT on pregnancy outcomes.

METHODS

Totally, 261 frozen-thawed embryo transfer cycles of 243 RIF women were included in this multicenter retrospective analysis. According to different embryo quality and transfer strategies, they were divided into four groups: group A, good-quality SeET (GQ-SeET, n=38 cycles); group B, poor-quality or mixed-quality SeET (PQ/MQ-SeET, n=31 cycles); group C, good-quality DBT (GQ-DBT, n=121 cycles); and group D, poor-quality or mixed-quality DBT (PQ/MQ-DBT, n=71 cycles). The main outcome, clinical pregnancy rate, was compared, and the generalized estimating equation (GEE) model was used to correct potential confounders that might impact pregnancy outcomes.

RESULTS

GQ-DBT achieved a significantly higher clinical pregnancy rate (aOR 2.588, 95% CI 1.267-5.284, P=0.009) and live birth rate (aOR 3.082, 95% CI 1.482-6.412, P=0.003) than PQ/MQ-DBT. Similarly, the clinical pregnancy rate was significantly higher in GQ-SeET than in PQ/MQ-SeET (aOR 4.047, 95% CI 1.218-13.450, P=0.023). The pregnancy outcomes of GQ-SeET were not significantly different from those of GQ-DBT, and the same results were found between PQ/MQ-SeET and PQ/MQ-DBT.

CONCLUSION

SeET relative to DBT did not seem to improve pregnancy outcomes for RIF patients if the embryo quality was comparable between the two groups. Better clinical pregnancy outcomes could be obtained by transferring good-quality embryos, no matter whether in SeET or DBT. Embryo quality plays a more important role in pregnancy outcomes for RIF patients.

A Case Series Based on the Mixed Double-Embryo Transfer (MDET) Outcome in Patients With Recurrent Implantation Failure

Successful implantation of embryos depends on the synchronous cross-talks between the endometrial wall and the competent blastocyst within the window of implantation (WOI). Hence, the WOI has a major significance in assisted reproductive technology (ART). However, in some cases, women do not have fixed WOI in ART cycles in order to enhance the rate of successful clinical pregnancy. However, there have been stances where women do not have a fixed WOI, and it shifts in subsequent menstrual periods. This contributes to the chances of recurrent implantation failure (RIF). Another factor that contributes to RIF is erratic endometrial receptivity, which hinders the chances of successful implantation of the conceptus in the endometrium. This case series consists of four case studies where the patients were believed to be suffering from RIF due to variable WOI or erratic endometrial receptivity and the routine protocol followed nowadays failed to make them conceive. In order to resolve the condition, we proposed a novel strategy in an attempt to improve pregnancy rates in these cases. An innovative method of embryo transfer known as mixed double-embryo transfer (MDET), which involved the transfer of one day 3 embryo and one day 5 blastocyst on day 6 of progesterone, led to possible pregnancy outcomes. A viable pregnancy was validated based on the human chorionic gonadotropin (β-hCG) test report, and two of the cases delivered healthy babies. Thus, this case series provides a unique approach to addressing the issues of RIF. However, larger studies are required to validate the possible use of this technique.

Sequential embryo transfer versus double cleavage-stage embryo or double blastocyst transfer in patients with recurrent implantation failure with frozen-thawed embryo transfer cycles: a cohort study

Background

Recurrent implantation failure (RIF) is more common among patients receiving assisted reproductive treatment. Many efforts have been made to increase the incidence of clinical pregnancy among patients with RIF. The effect of the sequential transfer procedure, a two-step interval transfer of a cleavage-stage embryo followed by a blastocyst in one transfer cycle, on the clinical outcomes of RIF patients remains controversial.

Methods

In total, 1774 frozen-thawed embryo transfer (FET) cycles in RIF patients were included. Of these cycles, 302 were sequential embryo transfer (ET) cycles, 979 were double day 3 cleavage-stage ET cycles, and 493 were double blastocyst ET cycles. The primary outcomes were the rates of implantation, clinical pregnancy and multiple pregnancy, and the secondary outcomes were the rates of hCG positive, early miscarriage and ectopic pregnancy.

Results

The implantation, hCG positive, and clinical pregnancy rates in the sequential ET group (32.1%, 58.9%, 50.7%) were significantly higher than those in the day 3 cleavage-stage ET group (24.9%, 46.5%, 40.4%) and were similar to those in the blastocyst transfer group (30.1%, 56.4%, 47.1%). The early miscarriage rate in the blastocyst transfer group was significantly higher than that in the cleavage-stage ET group (17.2% vs. 8.1%, P <0.05), while the ectopic pregnancy rate in the blastocyst transfer group was significantly lower than that in the cleavage-stage ET group (0.4% vs. 3.0%, P <0.05). The multiple pregnancy rate in the sequential ET group was significantly lower than that in the cleavage-stage ET group (17.0% vs. 25.5%, P <0.05) and the blastocyst transfer group (17.0% vs. 27.6%, P <0.05). When cycles of blastocyst culture failure were excluded, the clinical pregnancy rate was significantly higher (55.7% vs. 47.1%, P <0.05), and the early miscarriage rate and multiple pregnancy rate were significantly lower (8.5% vs. 17.2%, 17.7% vs. 27.6%; P <0.05, respectively) in the sequential ET group than in the double blastocyst ET group.

Conclusions

Sequential embryo transfer in FET cycles could improve the clinical outcomes of patients with RIF.

The efficacy of sequential day 3 embryo and blastocyst transfer in patients with repeated implantation failure

OBJECTIVE

To evaluate the efficacy of sequential transfer that one cleavage-stage embryo on day 3 and one blastocyst on day 5 are sequentially transferred in the same treatment cycle over conventional day 3 embryo transfer and blastocyst transfer in patients with repeated implantation failure (RIF).

STUDY DESIGN

2836 frozen embryo transfer (FET) cycles in patients with RIF were divided into three groups according to female age: <35, 35-39 and >39 years old groups, and four groups depending on the number and period of embryo transferred: two day 3 embryo, two blastocyst, single blastocyst and sequential transfer groups; Pregnancy outcomes including implantation rate (IR), clinical pregnancy rate (CPR), abortion rate (AR), ectopic pregnancy rate (EPR), multiple pregnancy rate (MPR), live birth rate (LBR) and neonatal characteristics from all the groups were assessed.

RESULTS

Sequential transfer caused a significant increase in the IR, CPR and LBR over two day 3 embryo transfer and did not improve the IR, CPR and LBR over two blastocyst transfer in patients with RIF. Sequential transfer had higher CPR, MPR and LBR and lower IR than single blastocyst transfer. No significant differences were present in neonatal characteristics among the transfer protocol groups. Singleton group had a higher average gestational age and birthweight as well as a lower cesarean section rate, preterm labor rate and low birthweight rate than twin group. Additionally, the AR had no significant difference and the EPR of blastocyst transfer was low.

CONCLUSIONS

Sequential transfer was not an effective method to improve IR in patients with RIF, and blastocyst transfer with higher IR was suggested. Single blastocyst transfer could serve as an effective transfer protocol to reduce MPR.

Clinical outcome analysis of sequential transplantation of frozen-thawed embryo transfer cycle: a retrospective study

The sequential transplantation was a new mode of in vitro fertilization and embryo transfer. To compare the clinical outcomes of sequential transplantation, embryo transplantation and blastocyst transplantation during freeze-thaw embryo transfer cycle. The retrospective study was conducted on 767 patients who received freeze-thaw embryo transfer at Reproductive Medicine Center of Hangzhou Women Hospital from July 1, 2020 to June 30, 2021. According to the age of transplanted embryos, all patients were divided into sequential transplantation, embryo embryo transplantation group and blastocyst stage transplantation group. The clinical data, embryo status and pregnancy outcome of the 3 groups were compared, the number of transplanted embryos in the sequential group was significantly higher than that in the other 2 groups (P < .05). The implantation rate of blastocyst transplantation group was the highest, there was no statistical significance between the sequential transplantation group and the other 2 groups (39.13% vs 30.00%, 39.13 vs 43.50%). The multiple birth rate (30.77%) and spontaneous abortion rate (20.51%) were higher in the sequential transplantation group, and there was no significant difference among the 3 groups (P > .05). The sequential transplantation cycle can obtain a higher clinical pregnancy rate than the conventional single cycle transplantation, without causing the waste of transplanted embryos, and can be used as the choice mode of resuscitation transplantation cycle for some patients.

Effects of Intrauterine Infusion of Autologous Platelet-Rich Plasma in Women Undergoing Treatment with Assisted Reproductive Technology: a Meta-Analysis of Randomized Controlled Trials

Purpose This meta-analysis was conducted to systematically retrieve relevant randomized controlled trials (RCTs) and evaluate the effects of intrauterine infusion of autologous platelet-rich plasma (PRP) in women with thin endometrium, implantation or pregnancy failure undergoing treatment with assisted reproductive technology (ART).

Methods We conducted a systematic review and meta-analysis of the retrieved RCTs. Studies on the intrauterine infusion of PRP in women undergoing treatment with ART that were published in PubMed, the Cochrane library, Web of Science, and Embase from inception until June 2022 were included. The data were extracted and analyzed independently using the fixed-effects or random-effects model according to heterogeneity.

Results Seven RCTs involving 861 patients (435 in the intervention group and 426 in the control group) were included. The rates of clinical pregnancy (risk ratio [RR]: 2.51; 95% confidence interval [CI]: 2.0–3.13; P < 0.00001), chemical pregnancy (RR: 1.96; 95% CI: 1.58–2.45; P < 0.00001), live births (RR: 7.03; 95% CI: 3.91–12.6; P < 0.00001), and implantation (RR: 3.27; 95% CI: 1.42–7.52; P = 0.005) were significantly higher in the women who received PRP infusion than in the control group. No significant differences were noted in the miscarriage rate (RR: 0.98; 95% CI: 0.39–2.42; P = 0.96) between the two groups.

Conclusion In summary, intrauterine infusion of PRP may be an effective therapy for women with thin endometrium and recurrent implantation failure (RIF) undergoing treatment with ART. More population-based RCTs are warranted to verify the efficacy of our evidence.

Sequential (two-step) day 3/day 5 frozen-thawed embryo transfer: does it improve the pregnancy rate of patients suffering recurrent implantation failure?

The best time of endometrial receptivity is the missing part of the implantation puzzle in patients with recurrent in vitro fertilization (IVF) failure. There are various treatment plans and strategies to meet the best endometrial timing for implantation. However, the lack of synchronization of the good-quality embryo with the patient's individual "window of implantation" is the hypothesis for most IVF failures so far. Sequential embryo transfer (ET) theoretically extends the availability time of embryos on the window of implantation. The study aimed to evaluate the improvement of pregnancy rate in sequential (two-step) frozen-thawed embryo transfer (FET) on day 3/day 5 in individuals who suffer from repeated IVF failures. This randomized controlled trial study was done in a university-affiliated infertility center for women with repeated consecutive IVF failures. Two hundred women aged 20-39 years who met our inclusion criteria were included in the study between January 2020 and September 2021. Participants were allocated with a 1:1 ratio to either sequential (two-step) ET on day 3/day 5 (study group, n=100) and conventional day 5 FET (n=100, control group). The frozen-thawed embryos were transferred to hormone replacement therapy-prepared endometrium in both groups. The primary outcomes were clinical pregnancy and implantation rates. The secondary outcomes were early pregnancy loss and multiple pregnancies. The demographic and clinical characteristics of the two groups were comparable. Clinical pregnancy rates were significantly higher in the sequential (two-step) FET group (40%) compared to the day 5 group (19%) (P<0.001). The sequential transfer of frozen-thawed embryos on day 3/day 5 was more effective than regular day 5 for patients suffering from repeated IVF failure.

Sequential cleavage and blastocyst embryo transfer and IVF outcomes: a systematic review

BACKGROUND

Sequential embryo transfer has been proposed as a way to improve embryo implantation in women for in vitro fertilization (IVF), but the effect on pregnancy outcomes remains ambiguous. This systematic review was conducted to investigate the efficacy of sequential embryo transfer on IVF outcomes.

METHODS

A literature search was performed in the PubMed, Web of Science, Cochrane Library, ScienceDirect and Wanfang databases. Data were pooled using a random- or fixed-effects model according to study heterogeneity. The results are expressed as relative risks (RRs) with 95% confidence intervals (CIs). Heterogeneity was evaluated by the I² statistic. The study protocol was registered prospectively on INPLASY, ID: INPLASY202180019.

RESULTS

Ten eligible studies with 2658 participants compared sequential embryo transfer and cleavage transfer, while four studies with 513 participants compared sequential embryo transfer and blastocyst transfer. The synthesis results showed that the clinical pregnancy rate was higher in the sequential embryo transfer group than in the cleavage embryo transfer group (RR 1.42, 95% CI 1.26-1.60, P< 0.01) for both women who did experience repeated implantation failure (RIF) (RR 1.58, 95% CI 1.17-2.13, P< 0.01) and did not experience RIF (Non-RIF) (RR 1.44, 95% CI 1.20-1.66, P< 0.01). However, sequential embryo transfer showed no significant benefit over blastocyst embryo transfer.

CONCLUSION

The current systematic review demonstrates that sequential cleavage and blastocyst embryo transfer improve the clinical pregnancy rate over conventional cleavage embryo transfer. For women with adequate embryos, sequential transfer could be attempted following careful consideration. More high-grade evidence from prospective randomized studies is warranted.

Effect of platelet-rich plasma on pregnancy outcomes in infertile women with recurrent implantation failure: a randomized controlled trial

METHODS

This study was directed to assess the efficacy of autologous platelet-rich plasma (PRP) on pregnancy rate in recurrent implantation failure. Between 2016 and 2019, a total of 98 women who unsuccessful to be pregnant after three or more high-quality embryo transfers undergoing frozen-thawed embryo transfer with or without an intrauterine infusion of platelet-rich plasma. Thus, 0.5 ml of platelet-rich plasma at 4-6 times higher concentration than peripheral blood infused intrauterine 48 h before embryo transfer. A control group underwent standard protocol.

RESULTS

There were no significant differences between the two groups in terms of age, body mass index and duration and cause of infertility and total transferred embryos and kind of treatment protocol, but secondary infertility and endometrial thickness 96 h before embryo transfer, was more in the intervention group. The clinical pregnancy (48.3% versus 23.26; p = .001) and ongoing pregnancy (46.7% versus 11.7%; p = .001) and implantation rate (58.3% versus 25%; p = .001) was more significant in the intervention group rather than controls. In conclusion, intrauterine infusion of platelet-rich plasma 48 h before freeze-thawed embryo transfer may have more effectiveness in in vitro fertilization (IVF) outcomes in recurrent implantation failure.

Comparing sequential vs day 3 vs day 5 embryo transfers in cases with recurrent implantation failure: randomized controlled trial

OBJECTIVE

The recent improvement in sequential media has refocused its attention on the role of human blastocysts in ART, not only because of its advantages but also because of the possible cancellation of embryo transfer when relying on blastocyst transfer only. Hence, the idea of sequential transfer on day 3 and day 5 was proposed. Objective: To compare the pregnancy outcomes of sequential embryo transfer on day 3 and day 5, versus cleavage transfer on day 3 and blastocyst transfer on day 5 in cases of recurrent implantation failure.

METHODS

This was a prospective and randomized trial, in which 210 qualified patients with recurrent implantation failures undergoing IVF/ICSI were randomized into three groups, each group included 70 patients. Embryo transfer was performed in day 3 in the first group, day 5 (blastocyst transfer) in the second group and sequential embryo transfer in days 3 and 5 in the third group. We assessed pregnancy outcomes from all the three groups. Results: Clinical pregnancy and live birth rates were significantly higher in the sequential group than either group day-3 or day-5 of embryo transfer in cases with recurrent implantation failures.

CONCLUSIONS

Sequential embryo transfer in cases with recurrent implantation failures and adequate number of retrieved oocytes is associated with higher implantation and clinical pregnancy rates, and it is advocated for patients having an adequate number of good quality embryos.

Successful Pregnancy following Mixed Double Embryo Transfer in a Patient with Variable Window of Implantation

The process of embryo implantation is carried out during the receptive stage of the endometrium in the midluteal phase of the menstrual cycle, known as window of implantation (WOI). It has been assumed that the WOI is not a constant variable in all women and the determination of its displacement is of crucial importance, especially for patients with recurrent implantation failure (RIF). Furthermore, in rare cases it could have different duration and position in the menstrual cycle even in the same woman but during different periods. Here, we report a 37-year-old woman with RIF, who was previously classified as idiopathic but has now been diagnosed as having a variable WOI. This interpretation was done after the performance of immunohistochemical and histomorphological analyses of endometrial biopsies taken in the midluteal phase during three sequential menstrual cycles. In order to solve the problem with pinpointing a variable WOI, a specific type of embryo transfer, called mixed double embryo transfer (MDET), was done where one Day 3 and one Day 5 good quality embryos were transferred simultaneously 7 days after ovulation. A viable single pregnancy was confirmed by ultrasound scan and a healthy girl was born. This case showed a unique approach in overcoming the problem in RIF patients with variable WOI.