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de Moura GA, Rocha YM, Moura FLD, Freitas JDO, Rodrigues JPV, Gonçalves VP, Nicolete R. Immune system cells modulation in patients with reproductive issues: A systematic review approach. JBRA Assist Reprod 2024; 28:78-89. [PMID: 37962966 PMCID: PMC10936913 DOI: 10.5935/1518-0557.20230044] [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: 02/12/2023] [Accepted: 08/21/2023] [Indexed: 11/16/2023] Open
Abstract
The aim of this study was to carry out a systematic literature review to investigate the main immune cells responsible for implantation failures. We selected papers from PubMed, Embase and Virtual Health Library databases. Eligible articles included publications between January 1, 2010 and April 24, 2022. Inclusion criteria were: observational and case-control studies; and the exclusion criteria were: review papers, letters to the editor, abstracts, animal studies and case reports. We extracted the following information: day of collection, number of patients, control group, age of patients, type of sample used, immune cells and cytokines. As main findings in our mapping, we found that in peripheral blood, CD3+, CD4+, CD8+, CD16+, CD56+, CD57+, CD69+, CD154+, CD158a+, NKp46 cells were increased and the CD4+, CD45+, Foxp3 and NKp46 markers were reduced. From the endometrial biopsies, there was an increase in CD3+, CD4+, CD5+, CD8+, CD16+, CD25+, CD45+, CD56+, CD57+, CD68+, CD127+ and a reduction in CD45+, CD56+, NKp46 and FoxP3 cells. Cytokines found increased in peripheral blood included IL-6, IL-10, IL-17, INF-γ, TGF-ß, TNF-α; while IL-4, IL-6, IL-10, IL-35, FoxP3, TGF-ß, SOCS3 were reduced. As for the biopsies, there was an increase in IL-2, IL-6, IL-17, IL-22, IL-23, INF-A1, INF-B1, INF-γ, TNF-R and a reduction in IL-6, IL-10, INF-γ, TGFß, TNF-α. We concluded that immune cells can be modulated during pregnancy failure, but further studies are needed to elucidate the modulating effect of the immune system on the endometrium of these patients.
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Affiliation(s)
- Gabriel Acácio de Moura
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | - Yasmim Mendes Rocha
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | | | | | - João Pedro Viana Rodrigues
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
| | - Vanessa Pinheiro Gonçalves
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
- North Northeast Biotechnology Network (RENORBIO), State University
of Ceará (UECE), Fortaleza, CE, Brazil
| | - Roberto Nicolete
- Post-Graduate Program in Pharmaceutical Sciences (PPGCF) Federal
University of Ceará (UFC), Fortaleza, CE, Brazil
- Oswaldo Cruz Foundation (FIOCRUZ CEARÁ), Eusébio, CE,
Brazil
- North Northeast Biotechnology Network (RENORBIO), State University
of Ceará (UECE), Fortaleza, CE, Brazil
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Stevens Brentjens LBPM, Obukhova D, Delvoux B, den Hartog JE, Bui BN, Mol F, de Bruin JP, Besselink D, Teklenburg G, Morgan F, Baker M, Broekmans FJM, van Golde RJT, Zamani Esteki M, Romano A. Local production of 17β-oestradiol in the endometrium during the implantation window: a pilot study. REPRODUCTION AND FERTILITY 2023; 4:e230065. [PMID: 37962510 PMCID: PMC10762592 DOI: 10.1530/raf-23-0065] [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: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 11/15/2023] Open
Abstract
Graphical abstract Abstract Sex steroids are converted to bioactive metabolites and vice versa by endometrial steroid-metabolising enzymes. Studies indicate that alterations in this metabolism might affect endometrial receptivity. This pilot study determined whether the endometrial formation and inactivation of 17β-oestradiol differed between the supposedly embryo-receptive endometrium and non-receptive endometrium of women undergoing IVF/intracytoplasmic sperm injection (ICSI). Endometrial biopsies were obtained from IVF/ICSI patients 5-8 days after ovulation in a natural cycle, prior to their second IVF/ICSI cycle with fresh embryo transfer (ET). Endometrial biopsies from patients who achieved clinical pregnancy after fresh ET (n = 15) were compared with endometrial biopsies from patients that did not conceive after fresh ET (n = 15). Formation of 17β-oestradiol (oxidative 17β-hydroxysteroid dehydrogenases (HSDs)), oestrone (reductive HSD17Bs) and inhibition of HSD17B1 activity were determined by high-performance liquid chromatography. The endometrial transcriptome was profiled using RNA sequencing followed by principal component analysis and differentially expressed gene analysis. The false discovery rate-adjusted P < 0.05 and log fold change >0.5 were selected as the screening threshold. Formation and inactivation of 17β-oestradiol resulted similar between groups. Inhibition of HSD17B1 activity was significantly higher in the non-pregnant group when only primary infertile women (n = 12) were considered (27.1%, n = 5 vs 16.2%, n = 7, P = 0.04). Gene expression analysis confirmed the presence of HSD17B1 (encoding HSD17B1), HSD17B2 (encoding HSD17B2) and 33 of 46 analysed steroid metabolising enzymes in the endometrium. In the primary infertile subgroup (n = 10) 12 DEGs were found including LINC02349 which has been linked to implantation. However, the exact relationship between steroid-metabolising enzyme activity, expression and implantation outcome requires further investigation in larger, well-defined patient groups. Lay summary Sex hormones are produced and broken down by enzymes that can be found in the endometrium (the inner lining of the womb). This enzyme activity might influence the chances of becoming pregnant. We compared (i) enzyme activity in the endometrium of 15 women who did and 15 women who did not become pregnant in their second in vitro fertilisation attempt, (ii) how enzyme activity can be blocked by an inhibitor, and (iii) differences in gene expression (the process by which instructions in our DNA are converted into a product). Enzyme activity was similar between groups. We found that in women who have never been pregnant in the past, inhibition of enzyme activity was higher and found differences in a gene that has been linked to the implantation of the embryo, but future studies should be performed in larger, well-defined patient groups to confirm these findings.
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Affiliation(s)
- L B P M Stevens Brentjens
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
| | - D Obukhova
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
- Department of Clinical Genetics, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - B Delvoux
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
| | - J E den Hartog
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
| | - B N Bui
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - F Mol
- Centre for Reproductive Medicine, Reproduction and Development, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - J P de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Henri Dunantstraat, Hertogenbosch, The Netherlands
| | - D Besselink
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid, Nijmegen, The Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, Dokter van Heesweg, Zwolle, The Netherlands
| | - F Morgan
- Department of Complex Tissue Regeneration, MERLN Institute, Maastricht University, Maastricht, The Netherlands
| | - M Baker
- Department of Complex Tissue Regeneration, MERLN Institute, Maastricht University, Maastricht, The Netherlands
| | - F J M Broekmans
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - R J T van Golde
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
| | - M Zamani Esteki
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
- Department of Clinical Genetics, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - A Romano
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Universiteitssingel, Maastricht, The Netherlands
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3
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Stevens Brentjens LBPM, Obukhova D, den Hartog JE, Delvoux B, Koskivuori J, Auriola S, Häkkinen MR, Bui BN, van Hoogenhuijze NE, Mackens S, Mol F, de Bruin JP, Besselink D, Teklenburg G, Kukushkina V, Salumets A, Broekmans FJM, van Golde RJT, Esteki MZ, Romano A. An integrative analysis of endometrial steroid metabolism and transcriptome in relation to endometrial receptivity in in vitro fertilization patients. F&S SCIENCE 2023; 4:219-228. [PMID: 37142054 DOI: 10.1016/j.xfss.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/27/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To study the relationship between the steroid concentration in the endometrium, in serum, and the gene expression level of steroid-metabolizing enzymes in the context of endometrial receptivity in in vitro fertilization (IVF) patients. DESIGN Case-control study of 40 IVF patients recruited in the SCRaTCH study (NTR5342), a randomized controlled trial investigating pregnancy outcome after "endometrial scratching." Endometrial biopsies and serum were obtained from patients with a first failed IVF cycle randomized to the endometrial scratch in the midluteal phase of the natural cycle before the next fresh embryo transfer during the second IVF cycle. SETTING University hopsital. PATIENTS Twenty women with clinical pregnancy were compared with 20 women who did not conceive after fresh embryo transfer. Cases and controls were matched for primary vs. secondary infertility, embryo quality, and age. INTERVENTION None. MAIN OUTCOME MEASURE(S) Steroid concentrations in endometrial tissue homogenates and serum were measured with liquid chromatography-mass spectrometry. The endometrial transcriptome was profiled by RNA-sequencing, followed by principal component analysis and differential expression analysis. False discovery rate-adjusted and log-fold change >|0.5| were selected as the threshold for differentially expressed genes. RESULT(S) Estrogen levels were comparable in both serum (n = 16) and endometrium (n = 40). Androgens and 17-hydroxyprogesterone were higher in serum than that in endometrium. Although steroid levels did not vary between pregnant and nonpregnant groups, subgroup analysis of primary women with infertility showed a significantly lower estrone concentration and estrone:androstenedione ratio in serum of the pregnant group (n = 5) compared with the nonpregnant group (n = 2). Expression of 34 out of 46 genes encoding the enzymes controlling the local steroid metabolism was detected, and estrogen receptor β gene was differentially expressed between pregnant and nonpregnant women. When only the primary infertile group was considered, 28 genes were differentially expressed between pregnant and nonpregnant women, including HSD11B2, that catalyzes the conversion of cortisol into cortisone. CONCLUSION(S) Steroidomic and transcriptomic analyses show that steroid concentrations are regulated by the local metabolism in the endometrium. Although no differences were found in endometrial steroid concentration in the pregnant and nonpregnant IVF patients, primary women with infertility showed deviations in steroid levels and gene expression, indicating that a more homogeneous patient group is required to uncover the exact role of steroid metabolism in endometrial receptivity. CLINICAL TRIAL REGISTRATION NUMBER The study was registered in the Dutch trial registry (www.trialregister.nl), registration number NL5193/NTR5342, available at https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6687. The date of registration is July 31, 2015. The first enrollment is on January 1, 2016.
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Affiliation(s)
- Linda B P M Stevens Brentjens
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Darina Obukhova
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Clinical Genetics, Maastricht University, Maastricht, the Netherlands
| | - Janneke E den Hartog
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Bert Delvoux
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | | | - Seppo Auriola
- University of Eastern Finland, School of Pharmacy, Kuopio, Finland
| | - Merja R Häkkinen
- Department of Health Security, Finnish Institute for Health and Welfare (THL), Kuopio, Finland
| | - Bich N Bui
- Department of Gynecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Nienke E van Hoogenhuijze
- Department of Gynecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Shari Mackens
- Center for Reproductive Medicine, UZ Brussel, Jette, Belgium
| | - Femke Mol
- Center for Reproductive Medicine, Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital-Hertogenbosch, the Netherlands
| | - Dagmar Besselink
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Gijs Teklenburg
- Isala Fertility Clinic, Isala Hospital, Zwolle, the Netherlands
| | | | - Andres Salumets
- Competence Centre on Health Technologies, Tartu, Estonia; Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Frank J M Broekmans
- Department of Gynecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ron J T van Golde
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Masoud Zamani Esteki
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Clinical Genetics, Maastricht University, Maastricht, the Netherlands
| | - Andrea Romano
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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4
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He Y, Liu L, Yao F, Sun C, Meng M, Lan Y, Yin C, Sun X. Assisted reproductive technology and interactions between serum basal FSH/LH and ovarian sensitivity index. Front Endocrinol (Lausanne) 2023; 14:1086924. [PMID: 37206442 PMCID: PMC10190590 DOI: 10.3389/fendo.2023.1086924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/10/2023] [Indexed: 05/21/2023] Open
Abstract
Objectives This study aimed to investigate whether the FSH (follicle-stimulating hormone)/LH (Luteinizing hormone) ratio correlates with ovarian response in a cross-sectional retrospective study of a population with normal levels of anti-Müllerian hormone (AMH). Methods This was a retrospective cross-sectional study with data obtained from medical records from March 2019 to December 2019 at the reproductive center in the Affiliated Hospital of Southwest Medical University. The Spearmans correlation test evaluated correlations between Ovarian sensitivity index (OSI) and other parameters. The relationship between basal FSH/LH and ovarian response was analyzed using smoothed curve fitting to find the threshold or saturation point for the population with mean AMH level (1.1<AMH<6μg/L). The enrolled cases were divided into two groups according to AMH threshold. Cycle characteristics, cycle information and cycle outcomes were compared. The Mann-Whitney U test was used to compare different parameters between two groups separated by basal FSH/LH in the AMH normal group. Univariate logistic regression analysis and multivariate logistic regression analysis were performed to find the risk factor for OSI. Results A total of 428 patients were included in the study. A significant negative correlation was observed between OSI and age, FSH, basal FSH/LH, Gn total dose, and Gn total days, while a positive correlation was found with AMH, AFC, retrieved oocytes, and MII egg. In patients with AMH <1.1 ug/L, OSI values decreased as basal FSH/LH levels increased, while in patients with 1.1<AMH<6 ug/L, OSI values remained stable with increasing basal FSH/LH levels. Logistic regression analysis identified age, AMH, AFC, and basal FSH/LH as significant independent risk factors for OSI. Conclusions We conclude that increased basal FSH/LH in the AMH normal group reduces the ovarian response to exogenous Gn. Meanwhile, basal FSH/LH of 3.5 was found to be a useful diagnostic threshold for assessing ovarian response in people with normal AMH levels. OSI can be used as an indicator of ovarian response in ART treatment.
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Affiliation(s)
- Yumei He
- Department of Gynecology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Ling Liu
- Department of Reproductive Medicine Center, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fei Yao
- Department of Gynecology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Chenyu Sun
- Department of Thyroid and Breast Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Muzi Meng
- UK Program Site, American University of the Caribbean School of Medicine, Preston, United Kingdom
- Bronxcare Health System, New York City, NY, United States
| | - Yunzhu Lan
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengliang Yin
- Faculty of Medicine, Macau University of Science and Technology, Macau, Macao SAR, China
- *Correspondence: Chengliang Yin, ; Xingyu Sun,
| | - Xingyu Sun
- Department of Gynecology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- *Correspondence: Chengliang Yin, ; Xingyu Sun,
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5
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van Hoogenhuijze NE, van Eekelen R, Mol F, Schipper I, Groenewoud ER, Traas MAF, Janssen CAH, Teklenburg G, de Bruin JP, van Oppenraaij RHF, Maas JWM, Moll E, Fleischer K, van Hooff MHA, de Koning CH, Cantineau AEP, Lambalk CB, Verberg M, van Heusden AM, Manger AP, van Rumste MME, van der Voet LF, Pieterse QD, Visser J, Brinkhuis EA, den Hartog JE, Glas MW, Klijn NF, van der Zanden M, Bandell ML, Boxmeer JC, van Disseldorp J, Smeenk J, van Wely M, Eijkemans MJC, Torrance HL, Broekmans FJM. Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial). Hum Reprod 2022; 37:254-263. [PMID: 34864993 PMCID: PMC8804332 DOI: 10.1093/humrep/deab261] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
STUDY QUESTION Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period? SUMMARY ANSWER The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution. WHAT IS KNOWN ALREADY Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth. STUDY DESIGN, SIZE, DURATION This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed. PARTICIPANTS/MATERIALS, SETTING, METHODS From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK). MAIN RESULTS AND THE ROLE OF CHANCE More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth. LIMITATIONS, REASONS FOR CAUTION There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now. WIDER IMPLICATIONS OF THE FINDINGS This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NL5193/NTR 5342).
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R van Eekelen
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Reproduction and Development, Amsterdam, The Netherlands
| | - I Schipper
- Division of Reproductive Endocrinology and Infertility, Department Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - C A H Janssen
- Department of Gynaecology, Groene Hart Hospital, Gouda, The Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, Zwolle, The Netherlands
| | - J P de Bruin
- Department of Gynaecology and Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | - J W M Maas
- Department of Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - E Moll
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M H A van Hooff
- Department of Gynaecology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - C H de Koning
- Department of Gynaecology, Tergooi Hospital, Hilversum, The Netherlands
| | - A E P Cantineau
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Verberg
- Fertility Clinic, Fertility Clinic Twente, Hengelo, The Netherlands
| | - A M van Heusden
- Fertility Clinic, Medisch Centrum Kinderwens, Leiderdorp, The Netherlands
| | - A P Manger
- Department of Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - L F van der Voet
- Department of Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Q D Pieterse
- Fertility Center, Haga Hospital, The Hague, The Netherlands
| | - J Visser
- Department of Gynaecology and Obstetrics, Amphia Hospital, Breda, The Netherlands
| | - E A Brinkhuis
- Department of Gynaecology and Obstetrics, Meander Hospital, Amersfoort, The Netherlands
| | - J E den Hartog
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - M W Glas
- Fertility Clinic, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - N F Klijn
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M van der Zanden
- Department of Gynaecology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - M L Bandell
- Department of Gynaecology, Albert Schweitzer Hospital, Sliedrecht, The Netherlands
| | - J C Boxmeer
- Department of Gynaecology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - J van Disseldorp
- Department of Gynaecology and Obstetrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Smeenk
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - M J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H L Torrance
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - F J M Broekmans
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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6
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Hysteroscopic endometrial peeling as a different approach to endometrial scratching. Case series report. J Gynecol Obstet Hum Reprod 2021; 50:102195. [PMID: 34245926 DOI: 10.1016/j.jogoh.2021.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022]
Abstract
STUDY QUESTION Does hysteroscopic endometrial peeling improve reproductive outcomes in women with implantation failure? DESIGN In this case series, 66 women underwent an hysteroscopic endometrial peeling and subsequently, a single frozen embryo transfer. RESULTS After the exclusion of patients with intraoperative incidental findings, pregnancy was achieved in 63% (42/66) of the women who underwent hysteroscopic endometrial peeling and subsequently a single frozen embryo transfer, clinical pregnancy rate was observed in 57% (38/66) of the patients and, clinical pregnancy loss occurred in 10% (4/38). CONCLUSION this novel surgical technique seems to increase implantation as well as clinical pregnancy rates in women with repeated implantation failure. We can hypothesize that the controlled and subtle degree of endometrial injury generated by the peeling generates an inflammatory cascade that enhances implantation.
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7
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van Hoogenhuijze NE, Mol F, Laven JSE, Groenewoud ER, Traas MAF, Janssen CAH, Teklenburg G, de Bruin JP, van Oppenraaij RHF, Maas JWM, Moll E, Fleischer K, van Hooff MHA, de Koning CH, Cantineau AEP, Lambalk CB, Verberg M, van Heusden AM, Manger AP, van Rumste MME, van der Voet LF, Pieterse QD, Visser J, Brinkhuis EA, den Hartog JE, Glas MW, Klijn NF, van der Meer S, Bandell ML, Boxmeer JC, van Disseldorp J, Smeenk J, van Wely M, Eijkemans MJC, Torrance HL, Broekmans FJM. Endometrial scratching in women with one failed IVF/ICSI cycle-outcomes of a randomised controlled trial (SCRaTCH). Hum Reprod 2021; 36:87-98. [PMID: 33289528 PMCID: PMC7801792 DOI: 10.1093/humrep/deaa268] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
STUDY QUESTION Does endometrial scratching in women with one failed IVF/ICSI treatment affect the chance of a live birth of the subsequent fresh IVF/ICSI cycle? SUMMARY ANSWER In this study, 4.6% more live births were observed in the scratch group, with a likely certainty range between −0.7% and +9.9%. WHAT IS KNOWN ALREADY Since the first suggestion that endometrial scratching might improve embryo implantation during IVF/ICSI, many clinical trials have been conducted. However, due to limitations in sample size and study quality, it remains unclear whether endometrial scratching improves IVF/ICSI outcomes. STUDY DESIGN, SIZE, DURATION The SCRaTCH trial was a non-blinded randomised controlled trial in women with one unsuccessful IVF/ICSI cycle and assessed whether a single endometrial scratch using an endometrial biopsy catheter would lead to a higher live birth rate after the subsequent IVF/ICSI treatment compared to no scratch. The study took place in 8 academic and 24 general hospitals. Participants were randomised between January 2016 and July 2018 by a web-based randomisation programme. Secondary outcomes included cumulative 12-month ongoing pregnancy leading to live birth rate. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with one previous failed IVF/ICSI treatment and planning a second fresh IVF/ICSI treatment were eligible. In total, 933 participants out of 1065 eligibles were included (participation rate 88%). MAIN RESULTS AND THE ROLE OF CHANCE After the fresh transfer, 4.6% more live births were observed in the scratch compared to control group (110/465 versus 88/461, respectively, risk ratio (RR) 1.24 [95% CI 0.96–1.59]). These data are consistent with a true difference of between −0.7% and +9.9% (95% CI), indicating that while the largest proportion of the 95% CI is positive, scratching could have no or even a small negative effect. Biochemical pregnancy loss and miscarriage rate did not differ between the two groups: in the scratch group 27/153 biochemical pregnancy losses and 14/126 miscarriages occurred, while this was 19/130 and 17/111 for the control group (RR 1.21 (95% CI 0.71–2.07) and RR 0.73 (95% CI 0.38–1.40), respectively). After 12 months of follow-up, 5.1% more live births were observed in the scratch group (202/467 versus 178/466), of which the true difference most likely lies between −1.2% and +11.4% (95% CI). LIMITATIONS, REASONS FOR CAUTION This study was not blinded. Knowledge of allocation may have been an incentive for participants allocated to the scratch group to continue treatment in situations where they may otherwise have cancelled or stopped. In addition, this study was powered to detect a difference in live birth rate of 9%. WIDER IMPLICATIONS OF THE FINDINGS The results of this study are an incentive for further assessment of the efficacy and clinical implications of endometrial scratching. If a true effect exists, it may be smaller than previously anticipated or may be limited to specific groups of women undergoing IVF/ICSI. Studying this will require larger sample sizes, which will be provided by the ongoing international individual participant data-analysis (PROSPERO CRD42017079120). At present, endometrial scratching should not be performed outside of clinical trials. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by ZonMW, the Dutch organisation for funding healthcare research. J.S.E. Laven reports grants and personal fees from AnshLabs (Webster, Tx, USA), Ferring (Hoofddorp, The Netherlands) and Ministry of Health (CIBG, The Hague, The Netherlands) outside the submitted work. A.E.P. Cantineau reports ‘other’ from Ferring BV, personal fees from Up to date Hyperthecosis, ‘other’ from Theramex BV, outside the submitted work. E.R. Groenewoud reports grants from Titus Health Care during the conduct of the study. A.M. van Heusden reports personal fees from Merck Serono, personal fees from Ferring, personal fees from Goodlife, outside the submitted work. F.J.M. Broekmans reports personal fees as Member of the external advisory board for Ferring BV, The Netherlands, personal fees as Member of the external advisory board for Merck Serono, The Netherlands, personal fees as Member of the external advisory for Gedeon Richter, Belgium, personal fees from Educational activities for Ferring BV, The Netherlands, grants from Research support grant Merck Serono, grants from Research support grant Ferring, personal fees from Advisory and consultancy work Roche, outside the submitted work. C.B. Lambalk reports grants from Ferring, grants from Merck, grants from Guerbet, outside the submitted work. TRIAL REGISTRATION NUMBER Registered in the Netherlands Trial Register (NL5193/NTR 5342). TRIAL REGISTRATION DATE 31 July 2015. DATE OF FIRST PATIENT’S ENROLMENT 26 January 2016.
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, 3015 GD, Rotterdam, the Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology & Reproductive Medicine, Noordwest Ziekenhuisgroep, 1782 GZ, Den Helder, the Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, 7334 DZ, Apeldoorn, the Netherlands
| | - C A H Janssen
- Department of Gynaecology, Groene Hart Hospital, 2803 HH, Gouda, the Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, 8025 AB, Zwolle, the Netherlands
| | - J P de Bruin
- Department of Gynaecology & Obstetrics, Jeroen Bosch Hospital, 5223 GZ, Den Bosch, the Netherlands
| | - R H F van Oppenraaij
- Department of Gynaecology, Maasstad Hospital, 3079 DZ, Rotterdam, the Netherlands
| | - J W M Maas
- Department of Gynaecology, Maxima Medical Centre, 5504 DB, Veldhoven, the Netherlands
| | - E Moll
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, 1061 AE, Amsterdam, the Netherlands
| | - K Fleischer
- Department of Obstetrics & Gynaecology, Radboud University Medical Centre, 6525 GA, Nijmegen, the Netherlands
| | - M H A van Hooff
- Department of Gynaecology, Franciscus Gasthuis en Vlietland, 3045 PM, Rotterdam, the Netherlands
| | - C H de Koning
- Department of Gynaecology, Tergooi Hospital, 1213 XZ, Hilversum, the Netherlands
| | - A E P Cantineau
- University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, the Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - M Verberg
- Fertility Clinic, Fertility Clinic Twente, 7556 BN, Hengelo, the Netherlands
| | - A M van Heusden
- Fertility Clinic, Medisch Centrum Kinderwens, 2353 GA, Leiderdorp, the Netherlands
| | - A P Manger
- Department of Gynaecology, Diakonessenhuis, 3582 KE, Utrecht, the Netherlands
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, 5623 EJ, Eindhoven, the Netherlands
| | - L F van der Voet
- Department of Gynaecology, Deventer Hospital, 7416 SE, Deventer, the Netherlands
| | - Q D Pieterse
- Fertility Center, Haga Hospital, 2545 AA, The Hague, the Netherlands
| | - J Visser
- Department of Gynaecology & Obstetrics, Amphia Hospital, 4818 CK, Breda, the Netherlands
| | - E A Brinkhuis
- Department of Gynaecology & Obstetrics, Meander Hospital, 3813 TZ, Amersfoort, the Netherlands
| | - J E den Hartog
- Department of Obstetrics & Gynaecology, Maastricht University Medical Centre, 6229 HX, Maastricht, the Netherlands
| | - M W Glas
- Fertility clinic, Wilhelmina Hospital Assen, 9401 RK, Assen, the Netherlands
| | - N F Klijn
- Department of Gynaecology, Leiden University Medical Centre, 2333 ZA, Leiden, the Netherlands
| | - S van der Meer
- Department of Gynaecology, Haaglanden Medical Centre, 2512 VA, The Hague, the Netherlands
| | - M L Bandell
- Department of Gynaecology, Albert Schweitzer Hospital, 3364 DA, Sliedrecht,the Netherlands
| | - J C Boxmeer
- Department of Gynaecology, Reinier de Graaf Gasthuis, 2625 AD, Delft, the Netherlands
| | - J van Disseldorp
- Department of Gynaecology & Obstetrics, St. Antonius Hospital, 3435 CM, Nieuwegein, the Netherlands
| | - J Smeenk
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, the Netherlands
| | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology - NVOG Consortium 2.0
| | - M J C Eijkemans
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands.,Julius Centre for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - H L Torrance
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - F J M Broekmans
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
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8
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Alfer J, Popovici RM, Fattahi A, Krieg J, Dittrich R, Beckmann MW, Hartmann A, Bleisinger N. Endometrial delay is found to be part of a normal individual dynamic transformation process. Arch Gynecol Obstet 2021; 304:1599-1609. [PMID: 34009460 PMCID: PMC8553713 DOI: 10.1007/s00404-021-06086-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/30/2021] [Indexed: 11/27/2022]
Abstract
Purpose Limited information is clinically available concerning endometrial receptivity; assessing endometrial transformation status is therefore an urgent topic in assisted reproductive technology. This study aimed to investigate individual endometrial transformation rates during the secretory phase in subfertile patients using personal endometrial transformation analysis. Methods Monitoring was carried out during the secretory phase to obtain endometrial receptivity profiles. For the investigation, two endometrial biopsies were taken within one menstrual cycle. The extended endometrial dating was based on the Noyes criteria, combined with immunohistochemical analyses of hormone receptors and proliferation marker Ki-67. Biopsies were taken mainly at days ovulation (OV, n = 76)/hormone replacement therapy (HRT, n = 58) + 5 and + 10. Results The results of the two biopsies were correlated with the clinically expected day of the cycle and showed temporal delays or hypercompensations, diverging from the expected cycle days by 0.5–5 days. In comparison with the first biopsies, the transformation rate in the second biopsies showed compensation, augmented delay, or constant transformation in 48.69, 22.37, and 28.94% of cases for ovulation in natural cycles and 56.89, 25.85, and 17.26% for HRT cycles, respectively. Conclusion The study revealed an individually dynamic transformation process of the endometrium, with the ability to compensate or enlarge an initial “delay”, which is now identified as a normal individual transformation process during the secretory phase. This information is of great importance for the scientific investigation of dynamic changes in endometrial tissue, as well as for the timing of embryo transfers.
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Affiliation(s)
- Joachim Alfer
- Department of Pathology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany.
- Kaufbeuren-Ravensburg Institute of Pathology, Elisabethenstrasse 19, 88212, Ravensburg, Germany.
| | | | - Amir Fattahi
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Obstetrics and Gynecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Ralf Dittrich
- Department of Obstetrics and Gynecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias W Beckmann
- Department of Obstetrics and Gynecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Arndt Hartmann
- Department of Pathology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Nathalie Bleisinger
- Department of Obstetrics and Gynecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
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9
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Mackens S, Racca A, Van de Velde H, Drakopoulos P, Tournaye H, Stoop D, Blockeel C, Santos-Ribeiro S. Follicular-phase endometrial scratching: a truncated randomized controlled trial. Hum Reprod 2021; 35:1090-1098. [PMID: 32372078 DOI: 10.1093/humrep/deaa018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 01/19/2020] [Indexed: 01/10/2023] Open
Abstract
STUDY QUESTION Does intentional endometrial injury (scratching) during the follicular phase of ovarian stimulation (OS) increase the clinical pregnancy rate (CPR) in ART? SUMMARY ANSWER CPR did not vary between the endometrial injury and the control group, but the trial was underpowered due to early termination because of a higher clinical miscarriage rate observed in the endometrial injury arm after a prespecified interim analysis. WHAT IS KNOWN ALREADY Intentional endometrial injury has been put forward as an inexpensive clinical tool capable of enhancing endometrial receptivity. However, despite its widespread use, the benefit of endometrial scratching remains controversial, with several recent randomized controlled trials (RCTs) being unable to confirm its added value. So far, most research has focused on endometrial scratching during the luteal phase of the cycle preceding the one with embryo transfer (ET), while only a few studies investigated in-cycle injury during the follicular phase of OS. Also, the persistence of a scratch effect in subsequent treatment cycles remains unclear and possible harms have been insufficiently studied. STUDY DESIGN, SIZE, DURATION This RCT was performed in a tertiary hospital setting between 3 April 2014 and 8 October 2017. A total of 200 women (100 per study arm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle followed by fresh ET were included. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were randomized with a 1:1 allocation ratio to either undergo a pipelle endometrial biopsy between Days 6 and 8 of OS or to be in the control group.The primary outcome was CPR. Secondary outcomes included biochemical pregnancy rate, live birth rate (LBR), early pregnancy loss (biochemical pregnancy losses and clinical miscarriages), excessive procedure pain/bleeding and cumulative reproductive outcomes within 6 months of the study cycle. MAIN RESULTS AND THE ROLE OF CHANCE The RCT was stopped prematurely by the trial team after the second prespecified interim analysis raised safety concerns, namely a higher clinical miscarriage rate in the intervention group. The intention-to-treat CPR was similar between the biopsy and the control arm (respectively, 44 versus 40%, P = 0.61, risk difference = 3.6 with 95% confidence interval = -10.1;17.3), as was the LBR (respectively, 32 versus 36%, P = 0.52). The incidence of a biochemical pregnancy loss was comparable between both groups (10% in the intervention group versus 15% in the control, P = 0.49), but clinical miscarriages occurred significantly more frequent in the biopsy group (25% versus 8%, P = 0.032). In the intervention group, 3% of the patients experienced excessive procedure pain and 5% bleeding. The cumulative LBR taking into account all conceptions (spontaneous or following ART) within 6 months of randomization was not significantly different between the biopsy and the control group (54% versus 60%, respectively, P = 0.43). LIMITATIONS, REASONS FOR CAUTION The trial was stopped prematurely due to safety concerns after the inclusion of 200 of the required 360 patients. Not reaching the predefined sample size implies that definite conclusions on the outcome parameters cannot be drawn. Furthermore, the pragmatic design of the study may have limited the detection of specific subgroups of women who may benefit from endometrial scratching. WIDER IMPLICATIONS OF THE FINDINGS Intentional endometrial injury during the follicular phase of OS warrants further attention in future research, as it may be harmful. These findings should be taken in consideration together with the growing evidence from other RCTs that scratching may not be beneficial. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by 'Fonds Wetenschappelijk Onderzoek' (FWO, Flanders, Belgium, 11M9415N, 1524417N). None of the authors have a conflict of interest to declare with regard to this study.
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Affiliation(s)
- S Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.,Research Group Reproduction and Immunology (REIM), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - A Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - H Van de Velde
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.,Research Group Reproduction and Immunology (REIM), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - P Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - H Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - D Stoop
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - S Santos-Ribeiro
- Reproductive Medicine, IVI-RMA Lisboa, Avenida Infante Dom Henrique 333 H 1-9, 1800-282 Lisbon, Portugal
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10
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Valizadeh A, Asghari S, Bastani S, Sarvari R, Keyhanvar N, Razin SJ, Khiabani AY, Yousefi B, Yousefi M, Shoae-Hassani A, Mahmoodpoor A, Hamishehkar H, Tavakol S, Keshel SH, Nouri M, Seifalian AM, Keyhanvar P. Will stem cells from fat and growth factors from blood bring new hope to female patients with reproductive disorders? Reprod Biol 2021; 21:100472. [PMID: 33639342 DOI: 10.1016/j.repbio.2020.100472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/21/2020] [Accepted: 12/06/2020] [Indexed: 01/05/2023]
Abstract
Female reproductive system disorders (FRSD) with or without infertility are prevalent women's health problems with a variety of treatment approaches including surgery and hormone therapy. It currently considering to sub-branch of regenerative medicine including stem cells or growth factors injection-based delivery treatment might be improved female reproductive health life. The most common products used for these patients treatment are autologous cell or platelet-based products from patients, including platelet-rich plasma, plasma rich in growth factor, platelet-rich fibrin, and stromal vascular fraction. In this review, we discuss each of the above products used in treatment of FRSD and critically evaluate the clinical outcome.
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Affiliation(s)
- Amir Valizadeh
- Stem Cell Research Center, Stem Cells and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran; Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samira Asghari
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Bastani
- Stem Cell Research Center, Stem Cells and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Raana Sarvari
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Keyhanvar
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Gene Yakhteh Keyhan (Genik) Company (Ltd), Pharmaceutical Biotechnology Incubator, Tabriz University of Medical Sciences, Tabriz, Iran; ARTAN1100 Startup Accelerator, Tabriz, Iran
| | - Sepideh Jalilzadeh Razin
- Stem Cell Research Center, Stem Cells and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Yousefzadeh Khiabani
- Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Bahman Yousefi
- Department of Clinical Biochemistry and Laboratory Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Shoae-Hassani
- Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran; Andam Baft Yakhteh (ABY) Company (Ltd), Tehran, Iran
| | - Ata Mahmoodpoor
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shima Tavakol
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Heidari Keshel
- Medical Nanotechnology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Tissue Engineering and Applied Cell Science, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Nouri
- Stem Cell Research Center, Stem Cells and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran; ARTAN1100 Startup Accelerator, Tabriz, Iran; Zist Andam Yakhteh Azerbaijan (ZAYA) Company (PHT), Medical Instrument Technology Incubator, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alexander Marcus Seifalian
- Nanotechnology and Regenerative Medicine Commercialization Centre (Ltd), The London Innovation Bio Science Centre, London NW1 0NH, United Kingdom
| | - Peyman Keyhanvar
- Stem Cell Research Center, Stem Cells and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran; ARTAN1100 Startup Accelerator, Tabriz, Iran; Zist Andam Yakhteh Azerbaijan (ZAYA) Company (PHT), Medical Instrument Technology Incubator, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Medical Nanotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; HealthNBICS Group, Convergence of Knowledge and Technology to the benefit of Society Network (CKTSN), Universal Scientific Education and Research Network (USERN), Tabriz, Iran.
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11
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Improving reproductive outcomes of intrauterine insemination: Does endometrial scratch injury help? A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2020; 253:225-231. [PMID: 32889329 DOI: 10.1016/j.ejogrb.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/03/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE(S) Current evidence suggests that endometrial injury improves clinical pregnancy rate while having no effect on miscarriages in women undergoing IVF/ICSI. However, there is no substantial evidence to advocate the use of endometrial injury to benefit the outcomes of IUI treatment. Additionally, there is no clear consensus about the ideal timing, underlying mechanism and optimum intensity of endometrial injury required. The study examines the effect of intentional endometrial injury/scratch in the early proliferative phase of stimulated cycle on reproductive outcomes (clinical and ongoing pregnancy rates and miscarriage occurrence) of intra-uterine insemination treatment (IUI). STUDY DESIGN, SIZE, DURATION This prospective, randomized control interventional study was conducted in a tertiary level teaching institution from April 2018 to February 2020. 150 eligible couples requiring IUI treatment who agreed to participate were randomly allocated on 1:1 basis to either control or intervention group. The trial participants received up to 3 cycles ovulation induction with clomiphene citrate and intra-uterine insemination. In addition, women in intervention group were subjected to endometrial scratch injury on day 6-7 of their stimulated cycle. 154 cycles in control arm and 128 cycles in intervention group were analyzed for clinical pregnancy, miscarriages and pain experienced by the women during endometrial scratch injury using the statistical package SPSS (version 21). RESULT Similar cumulative clinical pregnancy rates (12.5% Vs 13.6%, RR 1.21, 95% CI 0.44-3.37, p = 0.713), biochemical pregnancy rates (17.1% vs 22.9%, RR 1.43, CI 0.59-3.47, p = 0.421) and ongoing pregnancy rates (10.93% Vs 11.47%, RR 1.05, CI 0.35-3.21, p = 924) were observed in control and intervention arms. Likewise, the relative risk of miscarriage occurrence in the intervention arm was 1.32 (95% CI 0.39-4.32, p = 1.000) which was not statistically different from control group. Mean pain score of 6.93 on numerical pain rating scale was experienced by women whilst having endometrial scratch injury. CONCLUSIONS There is insufficient evidence to defend the use of endometrial scratch injury in intra-uterine insemination treatment, as it is moderately painful and have uncertain beneficial influence on reproductive outcomes.
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12
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Kemp A, El-Toukhy T. A narrative review of adjuvants in in vitro fertilisation: evidence for good clinical practice. J OBSTET GYNAECOL 2019; 40:295-302. [PMID: 31661334 DOI: 10.1080/01443615.2019.1647518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A review of studies published between January 1, 1984 and January 31, 2019 was performed with the aim of analysing the efficacy and adverse effects of commonly used adjuvants to in vitro fertilisation. The authors preferentially selected recent systematic reviews and randomised control trials (where available) from an electronic literature search. The review showed that low molecular weight heparin, corticosteroids and embryo glue may be of use in selected patient groups. Other adjuncts (such as growth hormone, assisted hatching, endometrial disruption and dehydroepiandrosterone) cannot currently be recommended as collated results showed no overall benefit to clinical pregnancy rates or live birth rates. There is a significant lack of robust evidence in this field, and areas in particular need of further research have been highlighted. In conclusion, caution should be exercised in prescribing adjuvants in in vitro fertilisation, either individually or in combination as further research is needed to ascertain their efficacy. Many adjuvants carry the risk of adverse effects which should also be considered. Patients should be clearly informed of the evidence, and where it is lacking, for these treatments. There is a need for further good quality trials to address the questions regarding best practice.
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Affiliation(s)
- Annabel Kemp
- Assisted Conception Unit, Guys and St Thomas's Foundation Trust, Guys Hospital, London, UK
| | - Tarek El-Toukhy
- Assisted Conception Unit, Guys and St Thomas's Foundation Trust, Guys Hospital, London, UK
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Should we stop offering endometrial scratching prior to in vitro fertilization? Fertil Steril 2019; 111:1094-1101. [PMID: 31155116 DOI: 10.1016/j.fertnstert.2019.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 12/12/2022]
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Sun L, Zhang S, Chang Q, Tan J. Establishment and comparison of different intrauterine adhesion modelling procedures in rats. Reprod Fertil Dev 2019; 31:1360-1368. [PMID: 30958978 DOI: 10.1071/rd18397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 02/07/2019] [Indexed: 01/14/2023] Open
Abstract
Intrauterine adhesion (IUA) is caused by endometrial damage and leads to the formation of scar fibrosis and repair disorders. We compared four different rat IUA modelling procedures in order to establish a stable animal model suitable for investigating IUA. Twenty female Sprague--Dawley rats were randomly divided into four groups. IUA was induced on one side of each rat uterus by ethanol instillation, heat stripping, mechanical injury or mechanical injury with infection (dual-injury); the other side of the uterus was left intact as a control. After 8 days the rats were sacrificed, their uteri were examined for histomorphology and expression of endometrial markers was checked using immunohistochemistry. All four IUA modelling procedures resulted in visual pathophysiological changes in the rat uterus, including stenosis, congestion and loss of elasticity. Endometrial thinning, shrinkage of glands and formation of fibrotic hyperplasia were also observed. All four procedures resulted in the downregulation of cytokeratin 18 and vimentin expression compared with control tissues, as well as the upregulation of collagen I expression. After mechanical injury and dual-injury the expression of interleukin 6 was significantly increased. Overall, our results suggest that ethanol instillation is the most stable IUA modelling procedure. Mechanical injury reliably yielded inflammatory indicators.
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Affiliation(s)
- Li Sun
- Assisted Reproduction Centre, Obstetrics and Gynaecology Department, Shengjing Hospital affiliated to China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang 110022, China; and Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodelling of Liaoning Province, Shengjing Hospital affiliated to China Medical University, Shenyang 110022, China
| | - Siwen Zhang
- Assisted Reproduction Centre, Obstetrics and Gynaecology Department, Shengjing Hospital affiliated to China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang 110022, China; and Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodelling of Liaoning Province, Shengjing Hospital affiliated to China Medical University, Shenyang 110022, China
| | - Qiyuan Chang
- Assisted Reproduction Centre, Obstetrics and Gynaecology Department, Shengjing Hospital affiliated to China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang 110022, China; and Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodelling of Liaoning Province, Shengjing Hospital affiliated to China Medical University, Shenyang 110022, China
| | - Jichun Tan
- Assisted Reproduction Centre, Obstetrics and Gynaecology Department, Shengjing Hospital affiliated to China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang 110022, China; and Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodelling of Liaoning Province, Shengjing Hospital affiliated to China Medical University, Shenyang 110022, China; and Corresponding author
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Sztachelska M, Ponikwicka-Tyszko D, Sokolowska G, Anisimowicz S, Czerniecki J, Lebiedzinska W, Zbucka-Kretowska M, Zygmunt M, Wołczynski S, Pierzynski P. Oxytocin antagonism reverses the effects of high oestrogen levels and oxytocin on decidualization and cyclooxygenase activity in endometrial tissues. Reprod Biomed Online 2019; 39:737-744. [PMID: 31548121 DOI: 10.1016/j.rbmo.2019.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/27/2022]
Abstract
RESEARCH QUESTION What is the in-vitro effect of oxytocin receptor (OTR) antagonism on parameters of receptivity in human endometrial explants and endometrial stromal cell lines cultured in oestradiol-rich conditions mimicking ovarian stimulation? DESIGN Experimental in-vitro study on endometrial tissue explants collected by aspiration biopsy from 30 women undergoing fertility treatment and cultured endometrial tHESC cell line. The study examined the effects of high oestradiol, oxytocin and OTR antagonist on parameters of decidualization (cell viability and prolactin secretion) as well as cyclooxygenase-1/2 (COX-1/2) activity and prostaglandin F2α (PGF2α) secretion. Changes in expression of OXTR and COX-2 genes were examined using quantitative polymerase chain reaction (qPCR). RESULTS In experiments on cultured endometrial cell line, high oestradiol and oxytocin similarly limited the viability of cells. In cultured endometrial explants both also decreased the secretion of prolactin (a marker of decidualization) and augmented endometrial COX-2 activity and formation of PGF2α. Oxytocin antagonist atosiban was confirmed to reverse the above effects, both in the endometrial line and endometrial explants. Addition of atosiban to cultures acted analogously in experiments employing both oxytocin and high oestradiol. CONCLUSIONS Oxytocin antagonist reversed the effects of high oestradiol and oxytocin on parameters related to endometrial receptivity in conditions mimicking ovarian stimulation. This might point to a novel, endometrium-related mechanism to support embryo implantation achieved by the application of oxytocin antagonist prior to embryo transfer.
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Affiliation(s)
- Maria Sztachelska
- Department of Biology and Pathology of Human Reproduction, Białystok, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10, Olsztyn 10-748, Poland
| | - Donata Ponikwicka-Tyszko
- Department of Biology and Pathology of Human Reproduction, Białystok, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10, Olsztyn 10-748, Poland
| | - Gabriela Sokolowska
- Department of Reproduction and Gynecological Endocrinology, Medical University of Białystok, M. Sklodowskiej-Curie 24a, Białystok 15-276, Poland
| | | | - Jan Czerniecki
- Department of Biology and Pathology of Human Reproduction, Białystok, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10, Olsztyn 10-748, Poland
| | - Weronika Lebiedzinska
- Department of Reproduction and Gynecological Endocrinology, Medical University of Białystok, M. Sklodowskiej-Curie 24a, Białystok 15-276, Poland
| | - Monika Zbucka-Kretowska
- Department of Reproduction and Gynecological Endocrinology, Medical University of Białystok, M. Sklodowskiej-Curie 24a, Białystok 15-276, Poland
| | - Marek Zygmunt
- Department of Obstetrics and Gynecology, University of Greifswald, Ferdinand-Sauerbruchstrasse, Greifswald D-17489, Germany
| | - Slawomir Wołczynski
- Department of Reproduction and Gynecological Endocrinology, Medical University of Białystok, M. Sklodowskiej-Curie 24a, Białystok 15-276, Poland
| | - Piotr Pierzynski
- Department of Reproduction and Gynecological Endocrinology, Medical University of Białystok, M. Sklodowskiej-Curie 24a, Białystok 15-276, Poland.
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Gürgan T, Kalem Z, Kalem MN, Ruso H, Benkhalifa M, Makrigiannakis A. Systematic and standardized hysteroscopic endometrial injury for treatment of recurrent implantation failure. Reprod Biomed Online 2019; 39:477-483. [PMID: 31405721 DOI: 10.1016/j.rbmo.2019.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/13/2019] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
RESEARCH QUESTION To investigate the effect of hysteroscopic endometrial injury for treatment of recurrent implantation failure (RIF). DESIGN This prospective and randomized controlled trial included 239 patients who had failed to achieve a clinical pregnancy after the transfer of at least four good-quality embryos in a minimum of three fresh or frozen-thawed embryo transfer cycles and were under the age of 40 years, who were randomized into two groups. The injury group (n = 124) received endometrial injury during their hysteroscopic procedure, whereas the control group (n = 115) did not. Patients who had endometrial pathologies were excluded from the study. RESULTS There were no statistically significant differences in duration of gonadotrophin use (8.23 versus 8.30 days), total dose of gonadotrophins (2330 versus 2338 IU), number of oocytes (7.03 versus 8.21), number of mature oocytes (5.27 versus 6.02), number of fertilized oocytes (4.19 versus 4.55), number of good-quality embryos (2.07 versus 2.43), number of embryos transferred (1.97 versus 1.93) or endometrial thickness (9.04 versus 9.35 mm) between the injury group and control group, respectively. Clinical pregnancy rates (25.8% versus 15.6%, P = 0.047), live birth rates (21.8% versus 12.2%, P = 0.049) and implantation rates (14.2% versus 8.8%, P = 0.036) were significantly different, favouring the injury group. CONCLUSION This study suggests that endometrial injury is beneficial in RIF patients to increase the odds of implantation, clinical pregnancy and live birth.
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Affiliation(s)
- Timur Gürgan
- Gürgan Clinic Women's Health and IVF Centre, Ankara, Turkey; Bahcesehir University, Faculty of Medicine, Department of Obstetrics and Gynecology Istanbul, Turkey.
| | - Ziya Kalem
- Gürgan Clinic Women's Health and IVF Centre, Ankara, Turkey
| | - Müberra N Kalem
- Bahcesehir University, Faculty of Medicine, Department of Obstetrics and Gynecology Istanbul, Turkey
| | - Halil Ruso
- Gürgan Clinic Women's Health and IVF Centre, Ankara, Turkey; Gazi University, Faculty of Medicine, Department of Histology and Embryology, Ankara, Turkey
| | - Moncef Benkhalifa
- Reproductive Medicine and Reproductive Genetics University Hospital and PERITOX Laboratory, Picardy Jules Verne University, Amiens, France
| | - Antonis Makrigiannakis
- University of Crete, Medical School, Department of Obstetrics and Gynecology, Heraklion, Greece
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Likes CE, Cooper LJ, Efird J, Forstein DA, Miller PB, Savaris R, Lessey BA. Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression. J Assist Reprod Genet 2019; 36:483-490. [PMID: 30610661 PMCID: PMC6439015 DOI: 10.1007/s10815-018-1388-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic. METHODS All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group. RESULTS Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group. CONCLUSIONS Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.
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Affiliation(s)
- Creighton E Likes
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Leah J Cooper
- Obstetrics and Gynecology, University of South Carolina SOM-Greenville, 900 Grove Rd, Greenville, SC, USA
| | - Jessica Efird
- Obstetrics and Gynecology, University of South Carolina SOM-Greenville, 900 Grove Rd, Greenville, SC, USA
| | - David A Forstein
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Paul B Miller
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Ricardo Savaris
- Departamento de Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-903, Brazil
| | - Bruce A Lessey
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA.
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van Hoogenhuijze NE, Kasius JC, Broekmans FJM, Bosteels J, Torrance HL. Endometrial scratching prior to IVF; does it help and for whom? A systematic review and meta-analysis. Hum Reprod Open 2019; 2019:hoy025. [PMID: 30895265 PMCID: PMC6396643 DOI: 10.1093/hropen/hoy025] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 12/06/2018] [Accepted: 12/19/2018] [Indexed: 12/16/2022] Open
Abstract
STUDY QUESTION What is the effect of endometrial scratching in patients with or without prior failed ART cycles on live birth (LBR) and clinical pregnancy rates (CPR)? SUMMARY ANSWER It remains unclear if endometrial scratching improves the chance of pregnancy and, if so, for whom. WHAT IS KNOWN ALREADY Endometrial scratching is hypothesized to improve embryo implantation in ART. Multiple studies have been published, but it remains unclear if endometrial scratching actually improves pregnancy rates and, if so, for which patients. STUDY DESIGN, SIZE, DURATION For this review, a systematic search for published articles on endometrial scratching and ART was performed on 12 February 2018, in Pubmed, Embase and the Cochrane Library. PARTICIPANTS/MATERIALS, SETTING, METHODS Randomized controlled trials (RCTs) that evaluated endometrial scratching in the cycle prior to the stimulation cycle and reported CPR or LBR were included. RCTs investigating the effect of scratching during the stimulation cycle, or prior to cryo-thaw cycles were excluded. Studies were assessed using the Cochrane Risk of Bias tool. The effect of scratching was assessed for three different patient groups: patients with no prior IVF/ICSI treatment (Group 0), patients with one failed full IVF/ICSI cycle, including cryo-thaw cycles (Group 1) and patients with two or more failed full IVF/ICSI cycles (Group 2). A meta-analysis was performed when statistical heterogeneity was low; otherwise, a descriptive analysis was performed. MAIN RESULTS AND THE ROLE OF CHANCE Fourteen RCTs involving 2537 participants were included. Most RCTs contained a high or unclear risk of bias on one or more items. Substantial clinical and statistical heterogeneity was present; therefore meta-analysis for LBR and CPR could only be performed on Group 1. For this group, no differences between scratch and control were found for both LBR (risk ratio (RR) 1.01 [95%CI 0.68–1.51]) and CPR (RR 1.04 [95%CI 0.74–1.45]). For Groups 0 and 2, pooled analysis could not be performed, and for both groups the results of the individual RCTs were negative, neutral and positive. Miscarriage and multiple pregnancy rates were evaluated for the three groups (0, 1 and 2) together. Both outcomes were not significantly different between scratch and control (miscarriage rate RR 0.82 [95%CI 0.57–1.17] and multiple pregnancy rate RR 1.06 [95%CI 0.84–1.35]). Subgroup analysis, excluding trials with a risk of unintentional endometrial injury in the control group, was performed for Group 0 and 2 for LBR and CPR, and for the overall groups for miscarriage rate and multiple pregnancy rate. This reduced the heterogeneity and allowed for pooled analysis in these subgroups. Results of pooled analysis for the subgroups of Group 0 and 2 showed no significant difference for LBR, but CPR was significantly improved after endometrial scratching (Group 0 RR 1.28 [95%CI 1.02–1.62] and Group 2 RR 2.03 [95%CI 1.20–3.43]). Subgroup analysis of the overall groups showed no significant difference for miscarriage and multiple pregnancy rate. LIMITATIONS REASONS FOR CAUTION The main limitations were that many RCTs had a high or unclear risk of bias on one or several items, clinical heterogeneity was still present despite categorizing into three populations, and that not all RCTs could be included in the analyses because separate data for our three groups could not be provided. WIDER IMPLICATIONS OF THE FINDINGS It remains unclear if endometrial scratching improves the chance of pregnancy for women undergoing ART and, if so, for whom. This means endometrial scratching should not be offered in daily practice until results from large and well-designed RCTs and an individual patient data analysis become available. STUDY FUNDING/COMPETING INTERESTS No specific funding was sought for the study. The Department of Reproductive Medicine and Gynaecology funds of the University Medical Center of Utrecht were used to support the authors throughout the study period and preparation of the manuscript. None of the authors has a conflict of interest to declare. REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Room Number: F05.126, Utrecht, The Netherlands
- Correspondence address. E-mail:
| | - J C Kasius
- Department of Gynaecology, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - F J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Room Number: F05.126, Utrecht, The Netherlands
| | - J Bosteels
- Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - H L Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Room Number: F05.126, Utrecht, The Netherlands
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Effect of endometrial injury on in vitro fertilization pregnancy rates: a randomized, multicentre study. Arch Gynecol Obstet 2019; 299:1159-1164. [PMID: 30661093 DOI: 10.1007/s00404-019-05044-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine if endometrial injury prior to the first or second in vitro fertilization (IVF) cycle affects clinical pregnancy rates. METHODS This study was a randomized, multicentre, controlled study performed at three Canadian outpatient fertility clinics. Patients undergoing their first or second IVF cycle were randomized to a single endometrial injury 5-10 days prior to the start of gonadotropins in an IVF cycle compared to no injury. The primary outcome was clinical pregnancy rate. Secondary outcomes were live birth rates, implantation rate, endometrial thickness, number of oocytes retrieved and the rate of embryo cryopreservation. RESULTS Fifty-one women were randomized (25 in the en dometrial injury group and 26 in the control group); however, the study was terminated prematurely due to slow recruitment (target 332 patients). Groups were similar at baseline for: age, duration of infertility, BMI, day 3 FSH, and the number having first IVF cycle. The groups were similar for gonadotropin dose, endometrial thickness, number of oocytes retrieved, and embryo cryopreservation rate. The clinical pregnancy rate in the endometrial injury group was 52% (13/25) and 46% (12/26) in the control group (p = 0.45). Live birth rate in the endometrial injury group was 52% (13/25) and 35% (9/26) in the control group (p = 0.17). The implantation rate was also similar (58% vs. 45%, p = 0.17). CONCLUSIONS This study did not detect a difference in implantation, clinical pregnancy or live birth rates; however, the lack of difference in this study may be because it was underpowered. CLINICAL TRIALS REGISTRATIONS: gov: NCT01983423.
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Bui BN, Torrance HL, Janssen C, Cohlen B, de Bruin JP, den Hartog JE, van der Linden PJQ, Deurloo KL, Maas JWM, van Oppenraaij R, Cantineau A, Lambalk CB, Visser H, Brinkhuis E, van Disseldorp J, Schoot BC, Lardenoije C, van Wely M, Eijkemans MJC, Broekmans FJM. Does endometrial scratching increase the rate of spontaneous conception in couples with unexplained infertility and a good prognosis (Hunault > 30%)? Study protocol of the SCRaTCH-OFO trial: a randomized controlled trial. BMC Pregnancy Childbirth 2018; 18:511. [PMID: 30594169 PMCID: PMC6311044 DOI: 10.1186/s12884-018-2160-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/19/2018] [Indexed: 12/28/2022] Open
Abstract
Background In the Netherlands, couples with unexplained infertility and a good prognosis to conceive spontaneously (i.e. Hunault > 30%) are advised to perform timed intercourse for at least another 6 months. If couples fail to conceive within this period, they will usually start assisted reproductive technology (ART). However, treatment of unexplained infertility by ART is empirical and can involve significant burdens. Intentional endometrial injury, also called ‘endometrial scratching’, has been proposed to positively affect the chance of embryo implantation in patients undergoing in vitro fertilization (IVF). It might also be beneficial for couples with unexplained infertility as defective endometrial receptivity may play a role in these women. The primary aim of this study is to determine whether endometrial scratching increases live birth rates in women with unexplained infertility. Method A multicentre randomized controlled trial will be conducted in Dutch academic and non-academic hospitals starting from November 2017. A total of 792 women with unexplained infertility and a good prognosis for spontaneous conception < 12 months (Hunault > 30%) will be included, of whom half will undergo endometrial scratching in the luteal phase of the natural cycle. The women in the control group will not undergo endometrial scratching. According to Dutch guidelines, both groups will subsequently perform timed intercourse for at least 6 months. The primary endpoint is cumulative live birth rate. Secondary endpoints are clinical and ongoing pregnancy rate; miscarriage rate; biochemical pregnancy loss; multiple pregnancy rate; time to pregnancy; progression to intrauterine insemination (IUI) or IVF; pregnancy complications; complications of endometrial scratching; costs and endometrial tissue parameters associated with reproductive success or failure. The follow-up duration is 12 months. Discussion Several small studies show a possible beneficial effect of endometrial scratching in women with unexplained infertility trying to conceive naturally or through IUI. However, the quality of this evidence is very low, making it unclear whether these women will truly benefit from this procedure. The SCRaTCH-OFO trial aims to investigate the effect of endometrial scratching on live birth rate in women with unexplained infertility and a good prognosis for spontaneous conception < 12 months. Trial registration NTR6687, registered August 31st, 2017. Protocol version Version 2.6, November 14th, 2018.
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Affiliation(s)
- B N Bui
- University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - H L Torrance
- University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - C Janssen
- Groene Hart Hospital, Gouda, The Netherlands
| | - B Cohlen
- Isala Fertility Clinic, Zwolle, The Netherlands
| | - J P de Bruin
- Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - J E den Hartog
- Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | | | - J W M Maas
- Máxima Medical Centre, Veldhoven, The Netherlands
| | | | - A Cantineau
- University Medical Centre Groningen, Groningen, The Netherlands
| | - C B Lambalk
- Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - H Visser
- Tergooi Hospital, Hilversum, The Netherlands
| | - E Brinkhuis
- Meander Medical Centre, Amersfoort, The Netherlands
| | | | - B C Schoot
- Catharina Hospital, Eindhoven, The Netherlands
| | | | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynecology - NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - M J C Eijkemans
- University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - F J M Broekmans
- University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
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Mol BW, Bossuyt PM, Sunkara SK, Garcia Velasco JA, Venetis C, Sakkas D, Lundin K, Simón C, Taylor HS, Wan R, Longobardi S, Cottell E, D'Hooghe T. Personalized ovarian stimulation for assisted reproductive technology: study design considerations to move from hype to added value for patients. Fertil Steril 2018; 109:968-979. [DOI: 10.1016/j.fertnstert.2018.04.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 12/20/2022]
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Pye C, Chatters R, Cohen J, Brian K, Cheong YC, Laird S, Mohiyiddeen L, Skull J, Walters S, Young T, Metwally M. Induced endometrial trauma (endometrial scratch) in the mid-luteal menstrual cycle phase preceding first cycle IVF/ICSI versus usual IVF/ICSI therapy: study protocol for a randomised controlled trial. BMJ Open 2018; 8:e020755. [PMID: 29780028 PMCID: PMC5961587 DOI: 10.1136/bmjopen-2017-020755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Endometrial trauma commonly known as endometrial scratch (ES) has been shown to improve pregnancy rates in women with a history of repeated implantation failure undergoing in vitro fertilisation (IVF), with or without intracytoplasmic sperm injection (ICSI). However, the procedure has not yet been fully explored in women having IVF/ICSI for the first time. This study aims to examine the effect of performing an ES in the mid-luteal phase prior to a first-time IVF/ICSI cycle on the chances of achieving a clinical pregnancy and live birth. If ES can influence this success rate, there would be a significant cost saving to the National Health Service through decreasing the number of IVF/ICSI cycles necessary to achieve a pregnancy, increase the practice of single embryo transfer and consequently have a large impact on risks and costs associated with multiple pregnancies. METHODS AND ANALYSIS This 30-month, UK, multicentre, parallel group, randomised controlled trial includes a 9-month internal pilot and health economic analysis recruiting 1044 women from 16 fertility units. It will follow up participants to identify if IVF/ICSI has been successful and live birth has occurred up to 6 weeks post partum. Primary analysis will be on an intention-to-treat basis. A substudy of endometrial samples obtained during the ES will assess the role of immune factors in embryo implantation. Main trial recruitment commenced on January 2017 and is ongoing.Participants randomised to the intervention group will receive the ES procedure in the mid-luteal phase of the preceding cycle prior to first-time IVF/ICSI treatment versus usual IVF/ICSI treatment in the control group, with 1:1 randomisation. The primary outcome is live birth rate after completed 24 weeks gestation. ETHICS AND DISSEMINATION South Central-Berkshire Research Ethics Committee approved the protocol. Findings will be submitted to peer-reviewed journals and abstracts to relevant national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN23800982; Pre-results.
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Affiliation(s)
- Clare Pye
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robin Chatters
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull
| | - Kate Brian
- Patient and Public Involvement (PPI), Fertility Network UK, London, UK
| | - Ying C Cheong
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Susan Laird
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Lamiya Mohiyiddeen
- Saint Mary's Hospital - Central Manchester University Hospitals, Manchester, UK
| | - Jonathan Skull
- Fertility Unit - Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stephen Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tracey Young
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mostafa Metwally
- Fertility Unit - Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Santos-Ribeiro S, Mackens S, Tournaye H, Blockeel C, Stoop D. Endometrial receptivity enhancement through induced injury and repair during ovarian stimulation: the Receptivity Enhancement by Follicular-phase Renewal after Endometrial ScratcHing (REFRESH) trial protocol. Hum Reprod Open 2017; 2017:hox022. [PMID: 30895236 PMCID: PMC6276659 DOI: 10.1093/hropen/hox022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/13/2017] [Accepted: 10/19/2017] [Indexed: 01/05/2023] Open
Abstract
STUDY QUESTION Does intentional endometrial injury (i.e. endometrial scratching) during ART enhance pregnancy rates? SUMMARY ANSWER We propose a randomized controlled clinical trial in women performing ART in which the intervention group will undergo an additional endometrial biopsy during exogenous ovarian stimulation. WHAT IS KNOWN ALREADY Although endometrial receptivity has been extensively studied, the mechanisms behind the implantation of an embryo remain largely a mystery. Intentional endometrial injury has been put forward by many researchers as an inexpensive clinical tool capable of enhancing endometrial receptivity. However, despite its widespread use, the benefit of endometrial scratching is still a contentious and unresolved issue. STUDY DESIGN, SIZE, DURATION Pragmatic two-arm randomized, single-centre, controlled open-label trial in women undergoing exogenous gonadotropin ovarian stimulation for ART followed by a fresh embryo transfer in a gonadotropin-releasing hormone antagonist suppressed cycle. The trial will include 360 women in total with a 1:1 allocation ratio and an expected total duration of up to 45 months. PARTICIPANTS/MATERIALS, SETTING, METHODS Subjects in the intervention group will undergo an endometrial biopsy during the follicular phase, on the sixth to eighth day of exogenous stimulation. Furthermore, nested within this clinical trial, we will also evaluate whether the transcriptomic signatures of the material collected during the biopsy may accurately distinguish women who become pregnant from those who do not. These endometrial transcriptomic signatures will be assessed both immediately after the biopsy and following in-vitro decidualization. MAIN RESULTS AND THE ROLE OF CHANCE Our primary objective is to assess the effect of endometrial injury during exogenous gonadotropin ovarian stimulation on clinical pregnancy rates after ART. Secondary efficacy and safety outcomes include: live-birth delivery after 24 weeks, the endometrial transcriptomic profile among women in the intervention group, short-term safety (e.g. procedure intolerance due to pain, post-procedure bleeding) and long-term safety (e.g. cancelled transfers, miscarriage) outcomes. LIMITATIONS, REASONS FOR CAUTION Owing to its pragmatic design, this study may have limited power to determine one or more of our secondary outcomes and whether there are specific subgroups of women who may benefit significantly from performing endometrial scratching and endometrial transcriptomic profiling. WIDER IMPLICATIONS OF THE FINDINGS Despite the weak biological plausibility, heterogeneity in the existing randomized controlled trials and lack of evaluation of any potential risks associated with endometrial scratching, this procedure is still widely applied in current clinical practice. This clinical trial aims to pragmatically assess the potential benefits and harms of the generalized use of this strategy. STUDY FUNDING/COMPETING INTEREST(S) this study has received a grant from the Research Foundation—Flanders (FWO, 1524417N). This organization has no further role in the study, namely with regards to protocol development, study conduction and evaluation of results. TRIAL REGISTRATION NUMBER NCT02061228. TRIAL REGISTRATION DATE 10 February 2014. DATE OF FIRST PATIENT’S ENROLMENT 3 April 2014. PROTOCOL VERSION 2.0.
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Affiliation(s)
- Samuel Santos-Ribeiro
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.,Department of Obstetrics, Gynaecology and Reproductive Medicine, Santa Maria University Hospital, Avenida Professor Egas Moniz, Lisbon 1649-035, Portugal
| | - Shari Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.,Department of Obstetrics & Gynaecology, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Dominic Stoop
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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