Repeated Implantation Failure Women Research Articles

P-395 Vaginal probiotics and vitamin D, as immunomodulatory approaches in improving the implantation and live birth in repeated implantation failure (RIF) women with imbalanced immune system

Abstract Study question Are vaginal probiotics and vitamin D (Vit.D) capable of improving implantation and live birth rate in RIF women with imbalanced immune system? Summary answer Vaginal probiotics and Vit.D are capable of improving the rate of implantation and live birth in RIF women with imbalanced immune system. What is known already RIF, determined as failure in achieving pregnancy after at least three in-vitro fertilization (IVF), is related to various factors including maternal and embryonic factors. Any abnormalities in maternal or embryonic part, such as maternal imbalanced immune profile, pose a risk for implantation. It has been estimated that endometrial microbiota and Vit.D would affect immune profile of endometrium and consequently, the process of implantation. Considering the effects of probiotics in normalizing the endometrium microbiota, it is likely that probiotics besides Vit.D regulate the imbalance of immune system in endometrium of RIF patients, to improve the rate of implantation and live birth. Study design, size, duration 148 women with a history of at least 3 consecutive implantation failures (from Feb 2021- Sep 2023), who referred to infertility centers of Valiasr International Hospital of Tabriz, were enrolled. Blood samples were taken, T helper 1 (Th1)/Th2 ratio (CD4+ interferon-γ (IFNγ)+/CD4+ interleukin-4 (IL-4)+ ratio) was evaluated by flowcytometry. Pregnancy (by the positive β- human chorionic gonadotropin (HCG) test and ultrasound) and live birth rate were also determined. Participants/materials, setting, methods The group of RIF women with elevated Th1/Th2 ratio (n = 65) was divided into 2 subgroups. The study group (n = 41) received probiotics (two capsules vaginally, every day for 6 months) and Vit.D (50,000 international unit (IU) every week for 10 weeks prior to the transfer). The control group (n = 24) received no treatment. At the end of the treatment, the embryo transfer was conducted. Finally, the pregnancy and live birth rate was evaluated. Main results and the role of chance Evaluation of pregnancy rate among the groups indicated that RIF women who received probiotics and Vit.D had a significantly higher rate of pregnancy (20/41, 48%) in comparison with no-treatment group (5/24, 20%). Live birth rate was also significantly higher in probiotics- and Vit.D-receiving RIF women (18/41, 43%) than no treatment group (3/24, 12%). Limitations, reasons for caution Lack of evaluation of endometrium microbiota, Vit.D level and local immune system profile prior to the study are the limitations of the current study. Wider implications of the findings The crucial role of balanced immune profile and presence of normal microbiota in the endometrium is undeniable for a successful implantation and pregnancy. Providing an optimum microbial microenvironment by probiotics and a favorable immunologic balance with Vit.D, as an immunomodulator, improves the implantation and pregnancy outcome of RIF patients. Trial registration number not applicable

Title: Repeated implantation failure is associated with increased Th17/Treg cell ratio, during the secretory phase of the human endometrium

Repeated implantation failure (RIF) is a significant limiting factor in assisted reproduction. Chronic endometrial inflammation has been noted in RIF women, therefore we sought to investigate the potential association of endometrial Th17/Treg ratio and endometrial inflammation in these cases. Endometrial pipelle biopsies were obtained from volunteers, 29 women with RIF (failure to achieve pregnancy following at least 3 transfers of high-grade embryos in IVF-cycles) and 27 fertile women (at least one child) in total, at the secretory phase of the menstrual cycle. Using tissues from 17 fertile and 18 RIF endometrial samples, stromal and immune cells were isolated and flow cytometry analysis was performed to determine Th17 and CD4+CD25high FOXP3+ cell populations in endometrial stromal cell suspensions. Another group of tissues from 10 fertile and 11 RIF samples were used for mRNA expression levels of Treg and Th17-cell transcription factors, FOXP3 and RORγt respectively. Endometrial inflammatory mediators’ mRNA expression was also analyzed. A statistically significant increase in protein flow cytometry analysis of Th17/Treg ratio (p≤0.05) as well as a reduction in absolute Treg cells in the endometrium (p≤0.05) was noted in women with RIF. Additionally, RNA analysis on the same set of women indicated RORγt/FOXP3 significantly increased in women with RIF compared to fertile ones (p≤0.05). Finally, women with RIF exhibited significantly (p≤0.05) elevated mRNA levels of pro-inflammatory mediators (ΤΝF-a, ΙL-6, IL-8 and CCl2). Women with RIF exhibit elevated Th17/Treg ratio, mostly due to endometrial Treg depletion, as well as a pro-inflammatory state in the endometrium.

Upregulated RPA2 in endometrial tissues of repeated implantation failure patients impairs the endometrial decidualization.

To investigate the expression and underlying mechanism of RPA2 in endometrium of patients with repeated implantation failure (RIF). In this study, we retrieved the expression profiles from GEO databases and filtered the differentially expressed genes between RIF and the fertile control group. Ultimately, RPA2 was confirmed as a target gene. RPA2 expression in endometrial tissues of RIF patients, the control group, and different phases was detected by RT-qPCR, immunohistochemistry, and Western blotting. The role of RPA2 in endometrial decidualization was performed by in vitro decidualization inducing by 8-Br-cAMP and MPA. Furthermore, RT-qPCR was used to detect changes in the decidual biomarkers after transfection of RPA2 overexpression vector in human endometrium stromal cell (HESC). RPA2 was significantly upregulated in the mid-secretory endometrium of patients with RIF. As a proliferation-related gene, RPA2 was obviously higher expressed at proliferative phase during the normal menstrual cycles. Moreover, the downregulation of RPA2 was discovered during decidualization of HESC. Furthermore, RPA2 overexpression impaired decidualization by inhibiting the expression of prolactin (PRL) and insulin-like growth factor-binding protein 1 (IGFBP1). Our finding indicated that aberrant upregulation of RPA2 attenuated decidualization of HESC in RIF women and provided new potential therapeutic targets.

P-485 Performance of ERA test after PGT-A in RIF patients defined according to ESHRE 2023 good practice recommendations: a retrospective case-control study

Abstract Study question Is Endometrial-Receptivity-Array (ERA) test clinically-useful among Repeated-Implantation-Failure (RIF) women defined according to ESHRE 2023 good-practice-recommendations (GPR) and undergoing single euploid blastocyst transfer? Summary answer ERA-test showed a higher “non-receptive endometrium” rate among RIF. Nevertheless, the live-birth-rate (LBR) per first euploid transfer was independent from progesterone timing according to ERA-test. What is known already ERA-test evaluates the expression of 238 genes from an endometrial biopsy. It aims at predicting the window of implantation and adjust progesterone timing accordingly. The data are controversial due to poor study design and/or limited sample size. Few studies investigated ERA-test in a setting with euploid transfers and/or among RIF patients. Moreover, RIF definition is largely inconsistent leading to a significant bias in the interpretation of the existing literature and treatment. ESHRE 2023 GPR revised RIF definition. Here, we leveraged this updated definition and PGT-A to assess ERA-test diagnostic/therapeutic performance in these women. Study design, size, duration Retrospective case-control study during 2013-2021 including 2211 patients with at least one euploid blastocyst after PGT-A. Hysteroscopy was conducted in case of suspect uterine pathologies, biopsy in case of suspect inflammation, and therapy in case of endometritis. 265 patients (12%) were classified RIF according to the ESHRE GPR (= no successful implantation despite an estimated cumulative chance ≥60%). 48 RIF patients requested ERA-test before undergoing vitrified-warmed euploid single blastocyst transfer, while 217 did not. Participants/materials, setting, methods qPCR/NGS-based PGT-A was conducted to assess non-mosaic aneuploidies. Normal thyroid function, vitamin-D levels, uterine cavity, and absence of sactosalpynx were confirmed. Whenever the ERA test suggested altered receptivity, progesterone timing was modified accordingly. The primary outcome was LBR per first euploid transfer in the non-ERA versus ERA groups, with a sub-analysis in ERA receptive versus non-receptive. Outcomes were adjusted for confounders assessed via logistic regressions. Main results and the role of chance RIF patients requesting ERA-test were older (39.1±4.5 versus 36.7±3.5 years, p < 0.01), and had already undergone 3.7±2.0 transfers resulted in implantation failures (1.5±1.3 of euploid blastocysts) versus 2.6±1.7 transfers (1.0±0.8 of which of euploid blastocysts) in the control (p < 0.01). Nevertheless, all these variables were not associated with the primary outcome under investigation. 44 non-RIF patients requested ERA-test in the same study period. Notably, the rate of pre-/post-receptive endometria was 39.6% (N = 19/48) among RIF and 13.6% (N = 6/44) among non-RIF women (p < 0.01). In fact, maternal age was not associated with “non-receptive” responses after ERA-test, the number of previous implantation failures showed an Odds-Ratio 1.29, 95%CI 1.03-1.62, p = 0.03. Blastocyst quality and day of full-blastulation were similar in ERA and non-ERA patients, as well as in ERA receptive and non-receptive patients. Positive pregnancy test, biochemical-pregnancy-loss, and miscarriage rates were all similar among non-ERA and ERA, and among ERA receptive and non-receptive patients. Indeed, also the LBR was similar among non-ERA and ERA (N = 98/220, 44.5% versus N = 17/48, 35.4%, p = 0.26; Odds-Ratio adjusted for blastocyst quality and day of full-blastulation: 0.76, 95%CI:0.39.1.48, p = 0.42) and among ERA receptive and non-receptive patients (N = 10/29, 34.5% versus N = 7/19, 36.8%, p = 0.99; Odds-Ratio adjusted for blastocyst quality and day of full-blastulation: 0.99, 95%CI:0.3-3.4, p = 0.99). Limitations, reasons for caution Our standard clinical workflow does not entail ERA-test, but the couple may request it. The study is retrospective with limited sample size. Patients requesting ERA-test were older with more previous failures. Non-ERA and ERA receptive patients underwent either Hormone-Replacement-Therapy or Modified-Natural-Cycle. Cost-effectiveness analyses are missing. Wider implications of the findings A promising association was reported between the novel definition of RIF and “non-receptive” responses, suggesting that ERA-test might unveil endometrial receptivity issues. Nevertheless, positive, and negative predictive values upon implantation are largely missing and its clinical utility as a therapeutic tool in RIF women remains questionable. Trial registration number none

Outcome of Different Endometrial Preparation Protocols Prior to Frozen-Thawed Embryo Transfer on Pregnancy Outcomes in Women with Repeated Implantation Failure.

To compare the pregnancy outcomes of frozen-thawed embryo transfer (FET) cycles among women with repeated implantation failure (RIF) treated with various endometrial preparation protocols. A total of 605 women with RIF were retrospectively recruited between January 2017 and December 2020 from Northern Theater General Hospital. Patients were divided into natural cycles, hormone replacement therapy (HRT) cycles, depot gonadotropin-releasing hormone (GnRH) agonist-HRT, and endometrial scratching (ES) plus depot GnRH agonist-HRT. The primary endpoint was clinical pregnancy rate, while secondary endpoints included live birth rate and pain assessment. Of the 605 recruited patients, 63 were undergoing natural cycles, 281 were treated with HRT cycles, 141 treated with depot GnRH agonist-HRT, and 120 treated with ES combined with depot GnRH agonist-HRT. There were significant differences among protocols on clinical pregnancy rate (P=0.029), while no significant difference was observed among protocols on live birth rates (P=0.108). Multivariate analyses suggested that HRT (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.28-0.89; P=0.019) and depot GnRH agonist-HRT (OR: 0.49; 95% CI: 0.27-0.91; P=0.021) cycles were associated with a lower clinical pregnancy rate as compared with natural cycles, while no significant difference between ES combined with depot GnRH agonist-HRT and natural cycles for clinical pregnancy rates (OR: 0.72; 95% CI: 0.38-1.36; P=0.313). Moreover, the HRT (OR: 0.70; 95% CI: 0.39-1.28; P=0.239), depot GnRH agonist-HRT (OR: 0.67; 95% CI: 0.35-1.29; P=0.229), and ES combined with depot GnRH agonist-HRT (OR: 1.11; 95% CI: 0.58-2.14; P=0.754) cycles had no significant effects on live birth rate as compared with natural cycles. A total of 87.50% patients treated with ES combined with depot GnRH agonist-HRT reported pain during the procedure. ES and depot GnRH agonists could be considered for RIF women with high-quality blastocysts, 14 days after verified transplantation failure.

Evaluation of CD3+ T Cell Percentage, Function and its Relationship with Serum Vitamin D Levels in Women with Recurrent Spontaneous Abortion and Recurrent Implantation Failure.

Women afflicted with recurrent spontaneous abortion (RSA) and repeated implantation failure (RIF) may have immune abnormalities. The role of vitamin D has been demonstrated in the function of the immune system. To assess the percentage and function of CD3+ T cells and their relationship with the level of the serum vitamin D or 1,25-dihydroxy vitamin D3 (the active form of the vitamin) in women with RSA and RIF. In this case-control study, peripheral blood was obtained from the patient and the healthy control groups. The ratio of CD3+T cell and activated CD3+ CD69+T cell was investigated using flow cytometry. The serum levels of Interferon-γ (IFN-γ) and vitamin D were measured by ELISA. The mean proportion of CD3+T cells in women with RSA increased significantly compared with the healthy control group (p<0.04). However, no significant difference was observed in RIF women compared with the control group. There was no significant difference in the ratio of activated CD3+CD69+T cells between the patient and the healthy control groups. Serum IFN-γ levels in women with RSA showed a significant increase compared to the control group (p<0.031); however, no significant difference was observed between women with RIF and the control group. Serum levels of vitamin D showed a significant reduction in both RSA (p<0.01) and RIF (p<0.04) groups in comparison with the control. An increase in the percentage and inflammatory function of T cells was associated with RSA. Decreased vitamin D levels may contribute to immune dysfunction and pregnancy loss.

Genital tract dysbiosis in infertile women with a history of repeated implantation failure and pilot study for reproductive outcomes following oral enteric coating lactoferrin supplementation

We prospectively investigated if oral enteric coating lactoferrin supplementation improves the reproductive outcomes in infertile women with a history of repeated implantation failure (RIF) and non-Lactobacillus-dominant (Lactobacillus rate < 90%) microbiota (NLDM) in vaginal secretions (VS)/endometrial fluid (EF). Paired VS/EF samples were obtained from RIF women and control infertile women (non-RIF group) for microbiome analysis. Chronic endometritis (CE) was diagnosed histopathologically and hysteroscopically. In a pilot study, oral enteric coating lactoferrin (700mg/day, at least 28 consecutive days) was administered to eligible patients with NLDM in VS/EF. Their reproductive outcomes in the subsequent vitrified-warmed embryo transfer cycles were followed up. While CE was more prevalent (OR 2.41, 95% CI 1.02-5.63, p = 0.042) in the RIF group (29.1%, n = 117) than in the non-RIF group (14.5%, n = 55), The NLDM rate was similar between the two groups (44.4 vs 52.7%). Lactoferrin supplementation improved NLDM in 43.2% of RIF women (n = 37). Within the RIF group, the live birth rate in the subsequent cycles was higher (OR 10.67, 95% CI 1.03 - 110.0, p = 0.046) in women with improved microbiota (57.1%, n = 14) than in those with unimproved microbiota (11.1%, n = 9). Unlike CE, NLDM was not unique to RIF but was common in infertile women. Although the therapeutic effect of the oral lactoferrin supplementation on NLDM was limited in a pilot study, the reproductive outcomes were better in RIF women who overcame NLDM than in those who failed. Randomized controlled trials are required to confirm the results. TRIAL REGISTRATION NUMBER AND DATE FOR PROSPECTIVELY REGISTERED TRIALS: UMIN-CTR 000036990, June 7, 2019.

Efficacy of the Intrauterine Infusion of Platelet-Rich Plasma on Pregnancy Outcomes in Patients With Repeated Implantation Failure: A Randomized Control Trial

Objectives: The aim of the present study was to evaluate the effect of the intrauterine administration of platelet-rich plasma (PRP) before embryo transfer (ET) on pregnancy outcomes in women with repeated implantation failure (RIF). Materials and Methods: This randomized controlled trial included 120 RIF women who were candidates for frozen-thawed ET. In the PRP group (n=60), the intrauterine infusion of 0.5 mL PRP was performed 48 hours before ET, and the control group (n=60) underwent ET without intrauterine administration. Results: The implantation rate (28% vs. 11.9%, P&lt;0.001), clinical pregnancy (51.6% vs. 26.6%, P=0.005), and live birth rate (58.3% vs. 28.3%, P=0.001) in PRP group were significantly higher compared to the control group. Based on the results, there was no significant difference with regard to miscarriage (12.5% vs. 12.9%, P=0.97) and multiple pregnancy rate (0.133% vs. 0.05%, P=0.11) between the two groups. Finally, preterm delivery was significantly higher in the PRP group (P&lt;0.001). Conclusions: According to this study, the result revealed that PRP is effective in the improvement of pregnancy outcomes in RIF patients. Further studies are needed to identify the group of patients who would benefit from this intervention.

Analysis of the risk factors and treatment for repeated implantation failure: OPtimization of Thyroid function, IMmunity, and Uterine Milieu (OPTIMUM) treatment strategy.

What are the pregnancy outcomes after the OPtimization of Thyroid function, Immunity, and Uterine Milieu (OPTIMUM) treatment strategy in patients with repeated implantation failure (RIF)? Infertile women with a history of RIF after more than three embryo transfer (ET) cycles underwent implantation testing, including a hysteroscopy, endometrial biopsy for CD138 immunostaining and bacterial culture, and serum 25-hydroxyvitamin D3 , interferon-γ-producing helper T (Th1) cell, IL-4-producing helper T (Th2) cell, thyroid-stimulating hormone, thyroid peroxidase antibody, and thrombophilia screening between April 2017 and August 2018. We treated chronic endometritis with antibiotics, aberrant high Th1/Th2 cell ratios with vitamin D and/or tacrolimus intake, overt/subclinical hypothyroidism with levothyroxine, and thrombophilia with low-dose aspirin. Of the 116 RIF women, 88 women with 133 ET cycles were recruited from a questionnaire-based survey regarding pregnancy outcomes. Fifty-nine consecutive RIF patients without the OPTIMUM treatment strategy were also recruited as a control. The 116 women with RIF after the OPTIMUM treatment strategy were 38.3±3.8years old and had an implantation failure history over 5 (3-19) ET cycles. Implantation testing identified impaired intrauterine circumstances in 75 women (64.7%), an aberrant elevated Th1/Th2 cell ratio in 56 women (48.3%), and thyroid abnormalities in 33 women (28.4%). Cumulative ongoing pregnancy rates including spontaneous pregnancy in the patients aged<40 and≥40years were 72.7% and 45.5% within two ET cycles, respectively. The pregnancy outcomes in the OPTIMUM group were significantly higher than those in the control. The OPTIMUM treatment strategy improved pregnancy outcomes in patients with RIF.

Anti-phospholipid antibody may reduce endometrial receptivity during the window of embryo implantation

BackgroundAnti-phospholipid antibodies (aPL) have been reported to be associated with repeated implantation failure (RIF), but the mechanism remains controversial. Endometrial receptivity is well known to be crucial for embryo implantation. This study aims to investigate the effect of aPL on endometrial receptivity in RIF women with positive aPL. MethodsSixty-four infertile women with normal menstrual cycles were enrolled. The control group comprised 32 pregnant women with negative aPL who conceived successfully after their first in vitro fertilization-embryo transfer (IVF-ET) cycle, and the RIF group comprised 32 women with positive aPL. Endometrial biopsy samples were collected seven days after the luteinizing hormone surge (LH + 7). The expression of LIF and HOXA10 was evaluated by immunohistochemistry, qRT-PCR and Western blot. Endometrial pinopode development was examined by scanning electron microscopy. ResultsThe mRNA expression of LIF and HOXA10 in the RIF group was significantly decreased compared with that in the control group during the implantation window. The immunohistochemistry and Western blot results confirmed these findings. Then, ultrastructural analyses of endometrial cells showed fewer pinopode processes, a more atypical morphology and increased atrophy in the RIF group compared with the control group, and these results were statistically significant. ConclusionaPL positivity may inhibit the expression of LIF and HOXA10 in the endometrium and influence pinopode development. Our findings suggest that positivity for aPL is associated with impaired endometrial receptivity, which results in the development of RIF.

Endometrial preparation using gonadotropin-releasing hormone agonist prior to frozen-thawed embryo transfer in women with repeated implantation failure: An RCT.

BackgroundPreparation of endometrial thickness in frozen-thawed embryo transfer (FET) is extremely important, particularly in repeated implantation failure (RIF) patients.ObjectiveThis study aimed to investigate the clinical outcomes of FET cycles among RIF women, based on the effects of administering gonadotropin-releasing hormone (GnRH) agonist prior to estrogen-progesterone preparation of the endometrium.Materials and Methods In this randomized clinical trial, 67 infertile women who were candidates for FET were divided into two groups: A) case group (n = 34), treated with GnRH agonist prior to endometrial preparation and B) control group (n = 33), which received the routine protocol. (6 mg daily estradiol started from second day) The clinical outcomes) including chemical and clinical pregnancy, in addition to implantation rates, were compared between the two groups.ResultsThe results showed no significant differences in women's age (p = 0.558), duration (p = 0.540), type (p = 0.562), and cause of infertility (p = 0.699). Regarding pregnancy and implantation rates, there was a trend toward an increase in the case group; however, differences were not statistically significant.ConclusionAlthough our results showed no significant differences between groups. Because there are trends to better results in case group larger sample size may show significant difference.

The uterine immunological changes may be responsible for repeated implantation failure

A significant part of couples in IVF-ICSI cycles experience Repeated Implantation Failure (RIF). Screening of the embryos with new methods like Next Generation Sequencing and arrays showed that even euploid embryos fail to implant. Immunology is a potent window maybe resolve the RIF problem. In this investigation we employed innate and adaptive immune system PCR array to compare the transcriptome profiles of endometrium in unexplained RIF and healthy fertile women.A total of 21 women were enrolled in the present study, 11women with unexplained RIF and 10 healthy fertile women. After RNA extraction and cDNA synthesis PCR array was performed using RT2 profiler PCR array human innate and adaptive immune responses kit (Qiagen, Cat.No: PAHS-052A). PCR Array data analysis identified significantly greater expression of IL6, IFNG, IL17A, IL23A, IFNA1, IFNB1, CD40 L, CCR4, CCR5, CCR6, CXR3, CCL2, IL2, TLR4, IRF3, STAT3, RAG1, IFNAR1 in unexplained RIF women than in controls (P < 0.05). However, expression of IL1B, IL8, NFKB, HLA-A, HLA-E, CD80, CD40 was significantly lower in unexplained RIF group than in controls (P < 0.05). Our results showed that modulation of immune system in RIF patient is shifted to inflammatory responses as pNK cells, Th17 signaling pathway and TLR signaling pathway are activated. So, by stimulation of immune system and initiation of humoral immune responses the panel of immunity and immunotolerance is completely changed in RIF patients comparing normal. It seems that attention to these alterations individually help physician to manage RIF patients better.

T cell Subsets in Peripheral Blood of Women with Recurrent Implantation Failure

The objective of this study was to determine whether there are any differences in the T cell composition and the expression of specific factors (i.e., IRF4, TBX21, GATA3, and GITR) of T cells between women with Repeated Implantation Failure (RIF) and fertile women. We observed a decrease in circulating Tregs and exhausted CD8 + T cells in RIF patients when compared to the controls whereas exhausted Treg and Th17 cells were more frequent. Using real-time PCR, we determined that the expression of IRF-4 and TBX21 was significantly elevated in the cases. In contrast, mRNAs encoding GATA3 and GITR were reduced. Furthermore, the expression of some miRNAs involved in T cell differentiation and their target gene candidates were examined in T cells from women with RIF and fertile control women. The patients showed significant up-regulation of miR-25, miR-93, and miR-326. miR-155 and miR-146a demonstrated significant down-regulation in RIF patients. The results revealed that the expression pattern of target genes was in line with data for miRNAs expression from purified Treg and Th17 cells. The findings of real-time PCR analysis provided insights into the genetic pathways underlying this aberration in the proportions of T cell subsets. Our data suggest that a combination of higher pro-inflammatory Th17 and exhausted Treg cells, and lower Treg and exhausted CD8 + T cells may co-exist in the peripheral blood of women with RIF. Moreover, the expression level of transcription factors and miRNAs controlling T cell differentiation may differ in women with RIF influencing pregnancy outcomes in these women.

Chemokine (C-C motif) ligand-2 (CCL2) and oxidative stress markers in recurrent pregnancy loss and repeated implantation failure

The main purpose of this study is to evaluate the inflammatory response and oxidative stress together in the cases of recurrent pregnancy loss (RPL) and repeated implantation failure (RIF). This is a cross-sectional study conducted to compare infertile patients who have RIF and patients with RPL histories in terms of CCL2, TAS, TOS, and OSI. To this end, two study groups were formed by primary-infertile women with RIF history and women with nulliparous RPL history who consulted a university hospital between 2014 and 2016, and a control group was formed by multiparous women who had no pregnancy loss. With 30 women in each group, 90 women in total were included in the study. CCL2, TAS, and TOS blood levels were measured and oxidative stress index was calculated in all participants. The patients with RPL and RIF had higher levels of CCL2 than those in the control group. The TOS, TAS, and OSI levels did not differ in RPL and RIF groups from the control group. No statistically significant relationship was found between CCL2 and the TOS, TAS, and OSI values. Oxidative stress markers in the pregestational period did not have a predictive value in the RPL and RIF. CCL2 might be useful in risk prediction.

Aberrant expressions of endometrial Id3 and CTLA-4 are associated with unexplained repeated implantation failure and recurrent miscarriage.

Inhibitor of DNA-binding protein 3 (Id3) is required for tumor angiogenesis and regulatory T-cell generation. However, the involvement of Id3 in unexplained repeated implantation failure (RIF) and recurrent miscarriage (RM) remains poorly understood. Immunohistochemistry was used to identify Id3, CD34, CTLA-4, and FOXP3 in the endometrium taken from the women with RIF (n=16), RM (n=16) and matched controls (n=8). The images were acquired and analyzed by the Vectra® automated quantitative pathology imaging system. Percentage of Id3+ cells was significantly higher in the endometrium of women with RIF and RM compared with controls. The numbers of Id3+ and CD34+ vessels in the endometrium were positively correlated in control but not in RIF or RM. Percentages of CTLA-4+ cells, but not FOXP3+ cells, were significantly increased in the endometrium of RIF and RM women than those in controls. We found aberrant expressions of endometrial Id3 and CTLA-4 in peri-implantation endometrium of women with RIF and RM, suggesting the negative roles of these angiogenesis and immune tolerance markers involving in regulating endometrium receptivity.

Thyroid Autoimmunity is Associated with Decreased Cytotoxicity T Cells in Women with Repeated Implantation Failure.

Thyroid autoimmunity (TAI), which is defined as the presence of autoantibodies against thyroid peroxidase (TPO) and/or thyroglobulin (TG), is related to repeated implantation failure (RIF). It is reported that TAI was involved in reproductive failure not only through leading thyroid function abnormality, but it can also be accompanied with immune imbalance. Therefore, this study was designed to investigate the association of thyroid function, immune status and TAI in women with RIF. Blood samples were drawn from 72 women with RIF to evaluate the prevalence of TAI, the thyroid function, the absolute numbers and percentages of lymphocytes. The prevalence of thyroid function abnormality in RIF women with TAI was not significantly different from that in RIF women without TAI (χ2 = 0.484, p > 0.05). The absolute number and percentage of T cells, T helper (Th) cells, B cells and natural killer (NK) cells were not significantly different in RIF women with TAI compared to those without TAI (all p > 0.05). The percentage of T cytotoxicity (Tc) cells was significantly decreased in RIF women with TAI compared to those without TAI (p < 0.05). Meanwhile, Th/Tc ratio was significantly increased (p < 0.05). These results indicated that the decreased Tc percentage and increased Th/Tc ratio may be another influential factor of adverse pregnancy outcomes in RIF women with TAI.

Hysteroscopy prior to repeat embryo transfer may improve pregnancy outcomes for asymptomatic women with repeated implantation failure.

The aim of this study was to evaluate the efficacy of hysteroscopy (HS) in detecting intrauterine abnormalities prior to repeat embryo transfer and improving pregnancy outcomes in asymptomatic women with repeated implantation failure (RIF). A prospective cohort study was conducted involving 672 asymptomatic RIF women from a Chinese university hospital. Pregnancy outcomes between the HS (subdivided into patients with and without intrauterine abnormalities) and non-HS groups were compared. The incidence of intrauterine abnormalities in the HS group was 37.13%. The most common abnormalities included endometrial polyps or polypoid endometrium, endometrial hyperplasia and intrauterine adhesions. Clinical pregnancy and implantation rates in the HS group were significantly higher than in the non-HS group (41.92% vs 32.25%; 23.82% vs 18.60%, respectively). There were no significant differences in early abortion, ectopic pregnancy, late abortion and live birth rates. The clinical pregnancy and implantation rates in both HS subgroups were significantly higher when compared to the non-HS group, whereas there were no significant differences between the subgroups. HS improved pregnancy outcomes in women with or without intrauterine abnormalities. HS may be routinely performed before repeat embryo transfer in RIF women.

Should zygote intrafallopian transfer be offered to all patients with unexplained repeated in-vitro fertilization cycle failures?

BackgroundOne of the suggest strategy for patients with repeated implantation failure (RIF) is zygote intrafallopian transfer (ZIFT). However, no data exist regarding to the issue of when and under which circumstances should ZIFT be offered to patients with RIF? We therefore aimed to examine whether repeated implantation failure (RIF) patients characteristics or their previous controlled ovarian hyperstimulation (COH) variables may differentiate between those who will conceive following a ZIFT cycle and those who will not.MethodsForty seven consecutive women admitted to our IVF unit during a 7 year period, who underwent ZIFT for RIF, were included. Ovarian stimulation characteristics, number of oocytes retrieved and number and quality of zygotes/embryos transferred were assessed and compared between the ZIFT cycle and the previous IVF/ICSI cycle and between those who conceived following the ZIFT cycle and those who did not.ResultsTwelve clinical pregnancies (clinical pregnancy rate- 25.5%) were recorded following the ZIFT cycle. Those who benefit from ZIFT were young patients (≤31 yrs), who underwent ≤6 cycle attempts, yielding over eight 2PN embryos with low (≤0.4) ratio of number of top-quality embryos to total 2PN embryos. Moreover, in those destined for a ZIFT cycle, only those with >7 2PN embryo should undergo a transfer of at least five 2PN embryos.ConclusionsFurther large prospective studies are needed to identify the specific characteristics of RIF women who may benefit from ZIFT.

Evaluation of Progesterone Receptor, FKBP51 and FKBP52, Associated with Uterine Receptivity, in Endometrial Tissue of Women with Repeated Implantation Failure

Background. Repeated implantation failure (RIF) is the most important problem in assisted reproductive technologies (ART). In the process of embryo implantation, accurate function of progesterone through progesterone receptors (PR) is crucial for establishment of a receptive endometrium. FKBP51 and FKBP52 are two co-chaperones acting as negative and positive regulators of PR function, respectively. Studies have shown that any deficiencies in expression of PR or its co-chaperones causes reproductive disorders. Materials and Methods. In this study we evaluated the PR protein expression by immunohistochemistry and expression of PR, FKBP51, FKBP52 genes by quantitative real-time PCR in endometrial tissue of normal and RIF women during the window of implantation. Results. Immunohistochemical studies showed that the PR protein expression in stromal cells is significantly higher in the endometrium of normal women than RIF women (P< 0.001). In addition, a significantly lower PR and FKBP52 gene expression was observed in endometrial tissue of RIF women compared to normal women (P< 0.001 and P< 0.001, respectively), whereas there was no significant difference in PR protein in epithelial cells (P= 0.3) and FKBP51 gene expression between the two groups (P= 0.6). Conclusion. The results indicate that altered expression of PR protein in stromal compartment and gene expression of PR and FKBP52 gene in endometrial tissue can be related to endometrial receptivity defects and occurrence of RIF

Effect of 1,25(OH)2 vitamin D3 on cytokine production by endometrial cells of women with repeated implantation failure

Repeated implantation failure (RIF) is a worldwide health problem that imposes a great deal of cost on patients and health care system. Vitamin D3 has been proposed to have positive impact on the process of implantation. The present study was performed to compare the effect of 1,25-dihydroxy vitamin D3 (1,25(OH)2D3) on cytokine production by endometrial cells of women with RIF and healthy fertile controls. Whole endometrial cells (WECs) and endometrial stromal cells (ESCs) from RIF and normal fertile women were treated with 1,25(OH)2D3. The levels of IL-10, TGF-β, IFNγ, Il-6, IL-8 and IL-17 in culture supernatants were assayed by ELISA. Also, ability of the cells from both groups to produce 1,25(OH)2D3 was evaluated and compared. 1,25(OH)2D3 down-regulated cytokine production in WECs from both groups except for IL-8 which was upraised. Similar trends were also observed in ESCs except up-regulation of TGF-β in RIF group. Endometrial cells of both groups had comparable capacity to produce 1,25(OH)2D3. Based on the minimal differential immunoregulatory effect of vitamin D3 on endometrial cells from RIF and control women, it may be suggested that circulating levels of maternal vitamin D3 be the subject of further investigation.