Efficacy of atosiban for repeated embryo implantation failure: A systematic review and meta-analysis

Atosiban in individuals with previous implantation failure undergoing frozen blastocyst transfer: a randomized controlled trial

STUDY QUESTION

Does the intravenous administration of Atosiban around the time of frozen blastocyst transfer to reduce uterine contractility increase the likelihood of live birth in individuals undergoing ART treatment?

SUMMARY ANSWER

In individuals with a history of one previous implantation failure, Atosiban did not significantly increase the live birth rates following frozen blastocyst transfer.

WHAT IS KNOWN ALREADY

Excessive uterine contraction waves during the embryo transfer procedure have been associated with decreased pregnancy rates. Atosiban, an oxytocin receptor antagonist, could reduce uterine contractions and potentially enhance implantation success in ART. However, data are inconclusive.

STUDY DESIGN, SIZE, DURATION

This study is a randomized, controlled, single-center, randomized, placebo-controlled clinical trial. Recruitment was from July 2019 to June 2023, with follow-up until May 2024. Participants, treating clinicians and embryologists were blinded to group assignment. Participants were randomized in a 1:1 ratio to receive intravenous Atosiban (37.5 mg) (n = 549) or placebo 30 min (n = 551) before the transfer procedure.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eleven hundred individuals scheduled for single frozen blastocyst transfer who had previously experienced one episode of implantation failure during ART. Uterine contractility was assessed via transvaginal ultrasound before administering the assigned intervention. The primary outcome was live birth. A pre-specified subgroup analysis was performed in individuals with and without abnormal uterine contractions.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 1100 randomized participants (mean age, 31 years), 1099 (99.9%) were assessed for the primary outcomes, with the exception of one participant in the placebo group who was lost to follow-up after clinical pregnancy. Live birth occurred in 272/549 (49.5%) in the Atosiban group and 246/550 (44.7%) in the placebo group (absolute difference 4.8%, 95% CI -1.1 to 10.7; risk ratio [RR] 1.11, 95% CI 0.98 to 1.26; P = 0.10). Uterine contractility was evaluated in 720 participants (65% of the total cohort). Among them, 163 participants (23%) with abnormal contractions had live birth rates of 51.9% and 39.3% in the Atosiban and placebo groups, respectively (absolute difference 12.6%, 95% CI -2.6 to 27.8; RR 1.32, 95% CI 0.94 to 1.86; P = 0.11).

LIMITATIONS, REASONS FOR CAUTION

The study's findings may not be widely applicable due to its single-center design, subjective video assessments, and focus on a specific subset of individuals experiencing failed embryo implantation, potentially introducing biases and confounding factors. Additionally, the limited examination of uterine contractions in only 65% of participants and the absence of re-evaluation due to resource constraints restrict the study's analytical power and the confirmation of Atosiban's effectiveness.

WIDER IMPLICATIONS OF THE FINDINGS

Our study shows do not support the routine use of intravenous Atosiban to improve pregnancy outcomes among individuals undergoing frozen embryo transfers.

STUDY FUNDING/COMPETING INTEREST(S)

Science and Technology Department of Shaanxi Province, China (2022SF-564); Innovation Team of Shaanxi Provincial Health and Reproductive Medicine Research (2023TD-04); Key Industrial Chain Projects in Shaanxi Province: Research on Assisted Reproductive Technologies and Precision Prevention System for Genetic Diseases Preconception (2023-ZDLSF-48); Northwest Women's and Children's Hospital, Xi'an, China and Ferring Pharmaceuticals (Shanghai) Company Limited. Ferring Pharmaceuticals (Shanghai) Company Limited supplied Atosiban free of charge. All funding parties had no role in study design, data collection, data analysis, data interpretation, writing of the report, or decisions to submit the results for publication. B.W.M. reports consultancy, travel support, and research funding from Merck and consultancy for Organon and Norgine; owning stock in ObsEva; and holding an NHMRC Investigator Grant (GNT1176437). W.L. is supported by an NHMRC Investigator grant (GNT2016729). All other authors declare no competing interests.

TRIAL REGISTRATION NUMBER

The RCT was registered in the Chinese Clinical Trial Registry; Study Number: ChiCTR1900022333.

TRIAL REGISTRATION DATE

5 April 2019.

DATE OF FIRST PATIENT’S ENROLMENT

1 July 2019.

Interventions for recurrent embryo implantation failure: An umbrella review

BACKGROUND

Recurrent implantation failure (RIF) has a multifactorial etiology. An umbrella review was undertaken to evaluate the multiple proposed interventions.

OBJECTIVES

To summarize and assess the strength of evidence of interventions for RIF from published systematic reviews (SR) of randomized clinical trials (RCTs).

SEARCH STRATEGY

After prospective registration (PROSPERO CRD42023414255), a systematic search was conducted in the Cochrane Library, Scopus and Medline from inception until March 2024.

SELECTION CRITERIA

SRs of RCTs, with or without meta-analyses (MA), were included if they reported clinical pregnancy rates (CPR) or live birth rates (LBR).

DATA COLLECTION AND ANALYSIS

The methodological quality of the included SRs was appraised independently in duplicate using the AMSTAR 2 tool. For each intervention, the MAs of RCTs with statistically significant improvements were counted as a percentage of the total assessing the strength of evidence using the GRADE system.

MAIN RESULTS

A total of 47 SRs were included: 32 reviews covered immunomodulatory interventions, 10 (68 RCTs) covered uterine and endometrial interventions, one covered antibiotics, and four (69 RCTs) addressed mixed approaches, including laboratory interventions. AMSTAR 2 appraised 41 (88%) SRs as critically low or low, and 6 (12%) as moderate or high in quality. The SRs often had a level of overlap of RCTs (median 33.3%), inconsistent definitions of RIF, and varied comparisons for the interventions. Considering the significant meta-analytic evidence of high-moderate GRADE strength: Granulocyte colony-stimulating factor (G-CSF) showed improvement in CPR in 9/13 (69.2%) MAs and LBR in 1/7 (14%); intralipid infusion showed improvement in CPR in 4/6 (57.14%) MAs and LBR in 3/4 (75%); peripheral blood mononuclear cells (PBMC) showed improvement in CPR in 4/8 (50%) MAs and LBR 3/5 (60%); platelet-rich plasma (PRP) intervention showed improvement in CPR in 6/10 (60%) MAs and LBR in 1/5 (20%); human chorionic gonadotropins showed improvement in CPR in 3/3 (100%) MAs; growth hormone showed improvement in CPR in 1/1 (100%) MA; low molecular weight heparin showed improvement in CPR in 1/1 (100%) MAs and LBR in 1/2 (50%); hysteroscopy showed improvement in CPR in 1/2 (50%) MAs; and, intentional endometrial injury showed improvement in CPR in 3/4 (75%) MAs and LBR in 2/3 (66.66%).

CONCLUSIONS

Evidence syntheses of RCTs evaluating interventions for RIF suggest a consistent direction, with high to moderate strength, indicating that immunomodulatory treatments, including G-CSF, PBMC, PRP, intralipid infusion, and intentional endometrial injury are likely to be effective. However, this conclusion should be interpreted with caution due to the generally low methodological quality of the included studies and the clinical heterogeneity observed in most SRs.

The efficacy of diazepam administration during embryo transfer: a retrospective multicenter cohort study on reproductive outcomes

PURPOSE

This retrospective multicenter cohort study aimed to investigate the impact of diazepam administration during embryo transfer on reproductive outcomes, focusing primarily on the live birth rate. Secondary outcomes included the positive beta-hCG rate, clinical pregnancy rate, miscarriage rate, ectopic pregnancy rate, and preterm birth rate.

METHODS

Data from 5607 embryo transfers, encompassing 465 cases with diazepam administration, were retrospectively analyzed. The study included single blastocyst transfers from 12 clinics in Portugal and Spain between January 2015 and December 2022.

RESULTS

Comparison of reproductive outcomes between patients receiving diazepam and those who did not showed no statistically significant differences. Positive beta-hCG rates (60.8% non-diazepam vs. 60.4% diazepam, p = 0.92, adjusted p = 0.32) and clinical pregnancy rates (45.6% non-diazepam vs. 46.2% diazepam, p = 0.81, adjusted p = 0.11) were comparable. Miscarriage rates (11.0% diazepam vs. 9.3% non-diazepam, p = 0.25, adjusted p = 0.26) and ectopic pregnancy rates (0.9% diazepam vs. 0.1% non-diazepam, p = 0.1, adjusted p = 0.20) were similar. Live birth rates (36.3% non-diazepam vs. 35.3% diazepam, p = 0.69, adjusted p = 0.82) and prematurity rates (0.3% non-diazepam vs. 0% diazepam, p > 0.99, adjusted p = 0.99) also exhibited no statistically significant differences.

CONCLUSIONS

Based on the results, diazepam administration during embryo transfer did not show a discernible impact on reproductive outcomes, including live birth rates, suggesting its limited effectiveness in enhancing success.

Improvement of early miscarriage rates in women with adenomyosis via oxytocin receptor antagonist during frozen embryo transfer-a propensity score-matched study

BACKGROUND

Dysfunctional uterine peristalsis seems to play a pivotal role in hindering embryo implantation among women diagnosed with adenomyosis. This research aims to investigate whether administering an oxytocin receptor antagonist during a frozen embryo transfer (FET) cycle using a hormone replacement therapy (HRT) protocol can enhance in vitro fertilization (IVF) outcomes for infertile women affected by adenomyosis.

METHODS

Between January 2018 and June 2022, our reproductive center conducted IVF-FET HRT cycles for infertile women diagnosed with adenomyosis. Propensity score matching was employed to select matched subjects between the two groups in a 1:1 ratio. Following this, 168 women received an oxytocin receptor antagonist during FET, constituting the study group, while the matched 168 women underwent FET without this antagonist, forming the control group. We conducted comparative analyses of baseline and cycle characteristics between the two groups, along with additional subgroup analyses.

RESULTS

The study group exhibited notably lower rates of early miscarriage compared to the control group, although there were no significant differences in clinical pregnancy rates, ongoing pregnancy rates, and live birth rates between the two groups. Multivariate analysis revealed a negative correlation between the use of oxytocin receptor antagonists and early miscarriage rates in women with adenomyosis. Subgroup analyses, categorized by age, infertility types, and embryo transfer day, showed a substantial decrease in early miscarriage rates within specific subgroups: women aged ≥ 37 years, those with secondary infertility, and individuals undergoing day 3 embryo transfers in the study group compared to the control group. Furthermore, subgroup analysis based on adenomyosis types indicated significantly higher clinical pregnancy rates, ongoing pregnancy rates and live birth rates in the study group compared to the control group among women with diffuse adenomyosis.

CONCLUSIONS

Administering an oxytocin receptor antagonist during FET may reduce the early miscarriage rates in women with adenomyosis.

Atosiban interacts with growth hormones as adjuvants in frozen-thawed embryo transfer cycles

Objective

To investigate the interaction between atosiban and growth hormone (GH) as adjuvants in frozen-thawed embryo transfer (FET) cycles.

Method

A total of 11627 patients who underwent FET at Xiamen University Affiliated Chenggong Hospital between January 2018 to December 2022 were retrospectively analyzed. Among them, 482 patients received atosiban and 275 patients received GH. The interactions were estimated by comparing the odds ratio (OR) for pregnancy comparing patients with or without atosiban adjuvant in cohorts stratified according to the presence of GH use in either the overall cohort or a propensity score (PS) matched cohort. An interaction term (atosiban × GH) was introduced to a multivariate model to calculate the ratio of OR (ORR) adjusted for confounders.

Results

For all patients receiving atosiban administration, no obvious effect on pregnancy was observed in comparison with either matched or unmatched controls. However, when the patients were stratified according to GH administration, atosiban showed a significant association with clinical pregnancy in comparison with either matched or unmatched controls among patients with GH treatment with rate ratios (RR) of 1.32 (95%CI: 1.05,1.67) and 1.35 (95%CI: 1,1.82), respectively. On the other hand, however, the association was absent among patients without GH treatment. The adjusted ORRs in both matched and unmatched cohorts were 2.44 (95%CI: 1.07,5.84) and 1.95 (95%CI: 1.05, 3.49) respectively.

Conclusion

The combination use of atosiban and GH in FET cycles is potentially beneficial to the pregnancy. However, indications for the use of atosiban and GH may need further assessment.

Effects of atosiban on clinical outcome in frozen-thawed embryo transfer: a propensity score matching study

PURPOSE

To evaluate the effects of atosiban on clinical outcomes in patients undergoing frozen-thawed embryo transfer.

METHODS

The clinical data of 1093 infertile patients who underwent frozen-thawed embryo transfer in our center from January 2019 to December 2020 were retrospectively analyzed (control, 418; atosiban, 675). Propensity score matching (PSM) analysis identified 400 matched pairs of patients. The implantation rate, clinical pregnancy rate, live birth rate, biochemical pregnancy rate, abortion rate, multiple pregnancy rate, and ectopic pregnancy rate between the two groups were compared.

RESULTS

Before PSM, patients differed by infertility factors, number of transferred embryos, and endometrial preparation protocol (P < 0.05). After PSM, characteristics were similar in corresponding patients of the atosiban and control groups. After propensity score matching, we found that there was no significant difference in the implantation rate, clinical pregnancy rate, live birth rate, biochemical pregnancy rate, abortion rate, multiple pregnancy rate, and ectopic pregnancy rate in atosiban and control group (P > 0.05).

CONCLUSION

Atosiban did not improve the clinical outcomes of infertile patients with frozen-thawed embryo transfer.

Atosiban application in fresh ET cycle is effective for women undergoing repeated embryo implantation failures, especially for advanced-age obese patients

To assess the effect of atosiban in pregnancy outcomes of the fresh embryo transfer (ET), the retrospective cohort study was conducted. Six hundred and eighty-nine cases (using atosiban) and 1377 age and ET cycle-matched controls were collected from the January 2016 to May 2022 to perform the fresh IVF-ET cycle. The essential characteristics and pregnancy outcomes were analyzed. Conditional logistic regression analysis and subgroup analysis were performed. In the whole samples, atosiban had no effects in the pregnancy outcomes. Subgroup analyses suggested that atosiban could improve the clinical pregnancy in more than 3 ET cycles (OR 1.667, 95% CI 1.108-2.509, P = 0.014). Moreover, the improvement of clinical pregnancy was mainly present in the advanced-age women (age ≥ 35 years: OR 1.851, 95% CI 1.136-3.014, P = 0.013), obesity (BMI ≥ 24 kg/m2: OR 2.550, 95% CI 1.105-5.883, P = 0.028) and cleavage stage embryo (D3 embryo: OR 1.721, 95% CI 1.098-2.696, P = 0.018) among the repeated implantation failures (RIF). Atosiban could also improve the live birth for the obese women. Further, in the RIF, atosiban application was strongly recommended for the advanced-age infertility women, who also had the risk of obesity with the implantation of the cleavage stage embryo. In conclusion, atosiban could improve pregnancy outcomes for the advanced-age and obese women in RIF, especially while implanting the cleavage stage embryo in fresh ET cycle.

Effects of melatonin against acute kidney injury: A systematic review and meta-analysis

INTRODUCTION

Melatonin is a hormone synthesized by the pineal gland, and has antioxidative effects in reducing acute kidney injury (AKI). In the past three years, an increasing number of studies have evaluated whether melatonin has a protective effect on AKI. The study systematically reviewed and assessed the efficacy and safety of melatonin in preventing AKI.

MATERIAL AND METHODS

A systematic literature search was conducted in the PubMed, Embase, and Web of Science databases on February 15, 2023. Eligible records were screened according to the inclusion and exclusion criteria. The odds ratio and Hedges' gwith the corresponding 95% confidence intervals were selected to evaluate the effects of melatonin on AKI. We pooled extracted data using a fixed- or random-effects model based on a heterogeneity test.

RESULTS

There were five studies (one cohort study and four randomized controlled trials) included in the meta-analysis. Although the glomerular filtration rate (GFR) may be significantly improved by melatonin, the incidence of AKI was not significantly decreased in the melatonin group compared with the control group in randomized controlled trials (RCTs).

CONCLUSIONS

In our study, the present results do not support a direct effect of melatonin use on the reduction of AKI. More well-designed clinical studies with larger sample size are required in the future.

Efficacy of atosiban for repeated implantation failure in frozen embryo transfer cycles

Atosiban was commonly added to improve pregnancy outcomes of patients with repeated embryo implantation failure (RIF). In this study, we aimed to investigate the effect of atosiban before transferring the frozen-thawed embryo to RIF patients. This retrospective study was conducted in the Hospital for Reproductive Medicine affiliated to Shandong University from August 2017 to June 2021. A total of 1774 women with a history of RIF undergoing frozen embryo transfer (FET) were included in this study. All the participants were classified into atosiban or control group: Group A included 677 patients who were administered atosiban intravenously 30 min prior to FET with a dose of 37.5 mg; Group B included 1097 patients who received no atosiban before the transfer. There were no significant differences observed in the live birth rate (LBR) (39.73% vs. 39.02%, P = 0.928) between the two groups. Other secondary outcomes including biochemical pregnancy rate, clinical pregnancy rate, implantation rate, clinical miscarriage rate and preterm birth rate were similar between the two groups (all P > 0.05). However, subgroup analysis demonstrated significantly higher preterm birth rates in the control group compared with the atosiban group (0 versus 3.0%, P = 0.024) in the natural FET cycles. Atosiban may not improve pregnancy outcomes of RIF patients in FET cycles. However, the effects of Atosiban on pregnancy outcomes should be assessed in clinical trials with larger sample sizes.