Modification of peripheric Treg and CD56brightNK levels in RIF women after egg donation, treated with GM-CSF or placebo

Recurrent implantation failure (RIF) is defined as when implantation repeatedly failed to reach a stage recognizable by pelvic ultrasound in IVF cycle and it may be due to several causes. The GM-CSF is a cytokine promoting leukocyte growth and trophoblast development: we tested it to treat these patients in a pilot-controlled trial evaluating the modification of peripheric Treg and CD56brightNK levels after the treatment with this cytokine and in control patients affected by RIF after egg donation cycles. This study was performed on 24 RIF women after egg donation cycles. Single good quality blastocyst transfer was performed in the cycle object of this study. Patients were randomly assigned to two groups: 12 women treated with subcutaneous GM-CSF 0.3 mg/kg/daily from the day before embryo transfer to the β-hCG day, and 12 women treated with subcutaneous saline solution infusion as control. All patients were tested for Treg and CD56brightNK cell levels in blood circulation before and after treatment using flow-cytometry with specific antibodies. The two groups of patients were similar for epidemiologic characteristics, the ongoing pregnancy rate in the GM-CSF group was 83.3% whereas in the control group was 25.0% (P = 0.0123). In the study group there was a significative increase of Treg cells (P < 0.001) with respect to the levels before treatment and to control group. Instead, the levels of CD56brightNK did not show any significative variation. Our study showed that the treatment with GM-CSF increases the Treg cells in the peripheric blood.

O-022 A randomised controlled trial on Recurrent Implantation Failure treatment in a study model performed on women who failed egg donation cycles using GM-CSF (MOLGRAMOSTIM)

Study question

Is the use of GM-CSF (molgramostim) effective in the treatment of recurrent implantation failure in egg donation cycles?

Summary answer

The clinical use of GM-CSF in women experienced implantation failure in egge donation cycles may be useful,

What is known already

The GM-CSF is a cytokine promoting leukocyte growth as well as trophoblast development. Recurrent implantation failure (RIF) is a clinical entity referring when implantation repeatedly failed to reach a stage recognizable by pelvic ultrasound in IVF cycles. There is no universally accepted definition for RIF. Several factors may determine implantation failure, such as maternal age, embyo aneuploidy, uterine anomalies. The efficacy of a specific treatment is difficult to test in this affection since embryos in general cases show an implantation rate of less than 50%.

Study design, size, duration

The study was conducted to the CERM-Hungaria, Rome, Italy, from the January 2020 to May 2021 on women with recurrent implantation failure after egg donation cycles. Inclusion criteria were: women, aged in between 35-49 years old underwent egg donation cycles with at least three previous transfers with good quality blastocysts that failed to reach pregnancy with no uterine defects (included adenomyosis), no systemic diseases.

Participants/materials, setting, methods

50 women with recurrent implantation failure after egg donation cycles. Patients were randomly subdivided in two groups: one (25 women) treated with subcutaneous GM-CSF (Molgramostim) 0.3mg/kg/daily from the day before embryo transfer to the b-hcg day. The treatment was continued until the 8th week of gestation: the control group (25 women) was treated with subcutaneous saline solution infusion in the same way of the study group. Primary outcome was the ongoing pregnancy rate.

Main results and the role of chance

Epidemiological data of the two groups did not show statistically significant differences. The ongoing pregnancy rate in the group treated with GM-CSF was 84.0% (21/25) whereas in the control group was 44.0% (11/25), P &lt; 0.0072. The absolute risk reduction was 40.0% (95%CI: 15.8%-64.2%). The NNT was 3.0 (95%CI: 1.6-6.3).

Limitations, reasons for caution

This study has a limited number of patients and more studies are needed to confirm these findings. Furthermore, recurrent implantation failure is a clinical entity difficult to classify and define, consequently to extrapolate a common indication for all patients with this should be carefully done.

Wider implications of the findings

The clinical use of GM-CSF in women experienced implantation failure may be an interesting treatment, if these data will confirmed, this treatment can be extended to all patients with recurrent implantation failure. Furthermore, the study model used may ba an interesting way to study recurrent implantation failure.

Trial registration number

NCT01718210

PreImplantation Factor in endometriosis: A potential role in inducing immune privilege for ectopic endometrium

Endometriosis is a chronic inflammatory condition characterised by the growth of endometrial epithelial and stromal cells outside the uterine cavity. In addition to Sampson’s theory of retrograde menstruation, endometriosis pathogenesis is facilitated by a privileged inflammatory microenvironment, with T regulatory FoxP3⁺ expressing T cells (Tregs) being a significant factor. PreImplantation Factor (PIF) is a peptide essential for pregnancy recognition and development. An immune modulatory function of the synthetic PIF analog (sPIF) has been successfully confirmed in multiple animal models. We report that PIF is expressed in the epithelial ectopic cells in close proximity to FoxP3⁺ stromal cells. We provide evidence that PIF interacts with FoxP3⁺ cells and modulates cell viability, dependent on cell source and presence of inflammatory mediators. Our finding represent a novel PIF-based mechanism in endometriosis that has potential for novel therapeutics.

Short gonadotropin-releasing hormone agonist versus flexible antagonist versus clomiphene citrate regimens in poor responders undergoing in vitro fertilization: a randomized controlled trial

OBJECTIVE

Poor responders represent a frustrating condition for couples undergoing IVF and clinicians, and their treatment remains disputed. To assess the efficacy and the most suitable protocol, we conducted a randomized controlled trial comparing three different protocols of ovarian stimulation in poor responder women: clomiphene citrate (CC) plus a high dose of gonadotropins and GnRH antagonist, flexible GnRH antagonist protocol and a short GnRH agonist protocol.

PATIENTS AND METHODS

Between July 2014 and December 2015 we enrolled 250 poor responders in a previous IVF cycle at least 3 months before. We divided into three groups: group A, 68 women treated with clomiphene citrate and FSH plus antagonist; Group B, 71 patients treated with FSH plus antagonist; Group C, 75 patients treated with FSH plus GnRH agonist.

RESULTS

The GnRH agonist protocol showed a significantly higher pregnancy rate (29.3% vs. 5.9% vs. 14.1% respectively) than the clomiphene and the GnRH antagonist protocol, number of mature oocytes collected, estradiol levels and endometrial thickness. The cost of medications for each baby born was lower for the GnRH agonist protocol than for the others; the implantation rate was significantly lower in the clomiphene group (4.8%) than in the GnRH antagonist group (9.3%) and the GnRH agonist groups (19.2%). No significant differences emerged for total FSH administered, days of stimulation, numbers of oocytes retrieved and embryos transferred.

CONCLUSIONS

This study demonstrates that short GnRH agonist protocol should be the first choice in poor responders; instead, clomiphene citrate should be avoided due to its very low success rate and high costs.

Ovarian Stimulation Protocol in IVF: An Up-to-Date Review of the Literature

The Assisted Reproductive Technology (ART) was born in order to help couples with infertility issues in having a baby. The first treatments of IVF used the spontaneous cycle of the women, with the retrieval of only one oocyte. Further studies have shown that it is possible to induce ovulation by administrating gonadotropins during the menstrual cycle, in order to obtain a higher number of oocytes. Many stimulation protocols have been introduced for controlled ovarian hyperstimulation of patients undergoing in vitro fertilization treatment. This review describe the different stimulation protocols using follicle-stimulating hormone (FSH) in combination with Gonadotropin releasing hormone (GnRH) either agonist or antagonist, oral supplementations and ovarian triggering. Using GnRH antagonist protocols have been demonstrated to improve significantly the clinical pregnancy rates for expected poor and high-responders, and in those women at high risk of developing ovarian hyperstimulation syndrome (OHSS). Two meta-analyses showed a better outcome in terms of the live birth rate when highly purified human menopausal gonadotropin (HMG) was used for ovarian stimulation compared with recombinant follicle stimulating hormone (rFSH) in the GnRH agonist long protocol. One of the most efficient stimulation protocol is the use of a combined protocol of human derived urinary FSH (uFSH) and rFSH. Combined protocol has resulted in a significant increase in the proportion of mature metaphase II oocytes and grade 1 embryos when compared to either rFSH or uFSH alone. A significantly higher delivery rate was achieved in rFSH+uFSH compared to the other protocols in poor and normal responders. Studying the combination of melatonin with myo-inositol and folic acid has also showed a higher percentage of mature oocytes in the melatonin group and a higher percentage of G1 embryos as well. However, It remains a crucial step to confirm the efficacy of such protocols for clinical application and it is still needs to comparison studies on larger scale with more focused on the differences in patients' response criteria and additional confounding variables, in order to draw more defined conclusions.

Expression of oct-4 and c-kit antigens in endometriosis

The objective of this study was to test the expression of the oct-4 and c-kit, both markers of stem cells, in the ectopic endometrial tissue of endometriotic lesions of women with severe endometriosis. Our findings show that ectopic epithelial cells express oct-4 and c-kit and this suggests that the ectopic endometrium in endometriosis has a stem cell origin and could explain the possible progression to ovarian cancer.

Clinical complications after transvaginal oocyte retrieval in 7,098 IVF cycles

We report the complications observed after transvaginal oocyte retrieval guided by ultrasound in 7,098 IVF cycles. The frequency of severe complications in our patients was 0.08%, of which four cases were intraperitoneal bleeding (0.06%) and two were cases of ovarian abscess (0.003%).

Urinary hMG (Meropur) versus recombinant FSH plus recombinant LH (Pergoveris) in IVF: a multicenter, prospective, randomized controlled trial

To compare IVF outcome in ovarian stimulation protocols with recombinant FSH plus recombinant LH versus hMG, 122 patients were randomized into two study groups: group A, patients treated with urinary hMG, and group B, patients treated with rFSH plus rLH. The two groups proved to be comparable to the main IVF outcome (pregnancy rate, implantation rate, oocytes, and embryos quality), with an increasing risk of ovarian hyperstimulation in the Pergoveris group.

Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles

OBJECTIVE

To determine the role of the natural cycle for in vitro fertilization (IVF) in poor responder patients.

DESIGN

Retrospective survey.

SETTING

Private center for assisted reproduction.

PATIENT(S)

294 women who were poor responders in a previous IVF cycle.

INTERVENTION(S)

Analysis of 500 consecutive natural cycles IVF.

MAIN OUTCOME MEASURE(S)

Number of cycles with oocytes, pregnancy rate per cycle, per transfer, and implantation rate.

RESULT(S)

Oocytes were found in 391 cases (78.1%), and cleaving embryos suitable for transfer were obtained in 285 cycles (57.0%). Pregnancy was observed in 49 cases, with a pregnancy rate of 9.8% per cycle, 17.1% per transfer, and 16.7% per patient. The patients were subdivided arbitrarily by the women's age into three groups. Patients 35 years old or younger showed a pregnancy rate of 18.1% per cycle, 29.2% per transfer, and 31.7% per patient. Women aged between 36 and 39 years showed a pregnancy rate of 11.7% per cycle, 20.6% per transfer, and 20.3% per patient. Women 40 years old or older showed a pregnancy rate of 5.8% per cycle, 10.5% per transfer, and 9.7% per patient. No differences were found for any of the evaluated parameters, independent of which cycle was the first, the second, third, fourth, or fifth, or further consecutive cycle.

CONCLUSION(S)

In poor responder patients, natural-cycle IVF is an effective treatment, especially in younger women.

Myolysis of Uterine Fibroids: Is There a Role?

Myolysis is among the new procedures under development for the treatment of symptoms related to uterine leiomyoma. The procedure targets the destruction of fibroids using one of a number of focused energy delivery systems including those based upon radiofrequency electricity, supercooled cryoprobes, and, most recently, focused ultrasound monitored by real time magnetic resonance imaging. For thermomyolysis and cryomyolysis, delivery of the energy requires access to the tissue by laparoscopy, and, in some instances, hysteroscopy. For focused ultrasound, the patient is detached from the energy source, which is delivered by an array of external beams. Clinical evaluation has been confined to case series, but it is evident that the approach results in a variable degree of reduction of the total uterine mass, and, usually, a reduction in uterine bleeding. Clearly, longer term appropriately designed comparative trials are required that evaluate and compare myolysis with myomectomy, uterine artery embolization, and hysterectomy, to name a few.

Urinary follicle-stimulating hormone (FSH) is more effective than recombinant FSH in older women in a controlled randomized study

OBJECTIVE

The following study was conducted to determine which FSH, recombinant or urinary, works better in older women.

DESIGN

We conducted a controlled randomized study in a single university IVF center.

SETTING

University IVF center.

PATIENT(S)

Women (N = 257) over 39 years old undergoing IVF.

INTERVENTION(S)

The patients were randomized into two study groups at their first IVF cycle: 121 patients were treated with recombinant FSH, and 120 patients were treated with urinary FSH. Both groups were suppressed with a long GnRH analog protocol.

MAIN OUTCOME MEASURE(S)

Days of stimulation, E2 at the day of hCG, total amount of FSH administered, number of oocytes collected, amount of FSH per oocyte, and number of embryos obtained.

RESULT(S)

Patients treated with urinary FSH required a significantly lower total amount of FSH, and a lower amount of FSH per oocyte than women treated with recombinant FSH. The other measures evaluated did not show any statistically significant differences.

CONCLUSION(S)

Our study showed that urinary FSH performed better in older women than recombinant FSH when associated with the long protocol.

Use of a medium buffered with N-hydroxyethylpiperazine-N-ethanesulfonate (HEPES) in intracytoplasmic sperm injection procedures is detrimental to the outcome of in vitro fertilization

OBJECTIVE

This study was conducted to determine whether N-hydroxyethylpiperazine-N-ethanesulfonate (HEPES)-buffered medium used for the microinjection of sperm into oocytes may be detrimental for the embryo.

DESIGN

Controlled randomized study.

SETTING

Private IVF center.

PATIENT(S)

Women (n = 708) undergoing ICSI.

INTERVENTION(S)

The women were randomized into two study groups: 2,204 oocytes from 357 women were treated using a medium buffered with bicarbonate without HEPES during the ICSI procedure, and 2,168 oocytes from 351 women were treated using a medium buffered with HEPES during the ICSI procedure.

MAIN OUTCOME MEASURE(S)

Fertilization rate, degeneration rate, triploid rate, cleavage rate, embryo quality, pregnancy rate, implantation rate, and abortion rate.

RESULT(S)

Oocytes treated with a HEPES-buffered medium showed a statistically significant higher rate of triploid and degenerated oocytes after fertilization with ICSI compared with oocytes treated with a medium without HEPES. The embryos obtained from oocytes microinjected with a HEPES-buffered medium showed a statistically significant higher rate of highly fragmented embryos compared with the controls. Pregnancy rate and implantation rate were statistically significantly lower in the patient group with oocytes treated with the HEPES-buffered medium. The other parameters evaluated did not show any statistically significant differences.

CONCLUSION(S)

Our study showed that the use of media buffered with HEPES, during the microinjection of sperm into the oocytes, is detrimental for IVF outcome and should be avoided.

Short versus long gonadotropin-releasing hormone analogue suppression protocols for superovulation in patients ≥40 years old undergoing intracytoplasmic sperm injection

OBJECTIVE

To determine whether the short or long protocol for controlled ovarian hyperstimulation works better in older patients undergoing IVF.

DESIGN

Controlled, randomized study.

SETTING

A single private IVF center.

PATIENT(S)

Two hundred twenty infertile women aged > or = 40 years undergoing IVF.

INTERVENTION(S)

At their first IVF cycle, the women were randomized into two study groups according to a computer-generated number sequence: 110 patients were treated with a long protocol, and the other 110 were treated with a short protocol for controlled ovarian hyperstimulation.

MAIN OUTCOME MEASURE(S)

Days of stimulation, E2 level at the day of hCG administration, amount of FSH administered, number of oocytes collected, number of embryos obtained, pregnancy rate, implantation rate.

RESULT(S)

Patients treated with a long protocol showed a significantly higher number of oocytes retrieved, a higher number of embryos obtained, and a higher pregnancy rate, both for cycle and transfer, compared with the short-protocol patients. The other parameters evaluated did not show any statistically significant differences.

CONCLUSION(S)

Our study showed that the long protocol performed better than the short protocol in older women. Our findings demonstrated that flare-up in older women might be detrimental.

Directed laparoscopic cryomyolysis for symptomatic leiomyomata: One-year follow up

STUDY OBJECTIVE

To evaluate the long-term effectiveness of laparoscopic cryomyolysis as a minimally invasive technique for the treatment of symptomatic uterine myomas in menstruating women.

DESIGN

Open, one-arm pilot study (Canadian Task Force classification II).

SETTING

University-affiliated public hospital.

PATIENTS

Twenty patients with symptomatic uterine myomas were treated with directed cryomyolysis. All had reported abnormal bleeding and/or pelvic pain/pressure and/or urinary frequency. Myoma diameters varied from 4 to 10 cm.

INTERVENTION

One-year follow-up after laparoscopic-directed cryomyolysis.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic cryomyolysis was performed using the Her Option Cryoablation Unit (American Medical Systems, Minneapolis, MN). Patients were evaluated 1, 3, 6, 9, and 12 months after surgery. Power color Doppler ultrasound was performed preoperatively and postoperatively to demonstrate the effectiveness of the technique in reducing or eliminating the primary blood supply to the myomas, as well documenting regression of the myomas. All patients reported a high rate of satisfaction with the treatment including absence of symptoms 12 months after surgery, with no bleeding and no myoma-related symptoms, comparable with patients who underwent hysterectomy. Mean shrinkage of myoma volume increased until 9 months after surgery (59.5% +/- 13.2%), reaching a steady mean-volume reduction of approximately 60% (61.9% +/- 11.9%) 12 months after surgery.

CONCLUSIONS

Directed laparoscopic cryomyolysis appears to be an effective and safe technique for providing rapid symptom relief and at least 12 months' effectiveness in the treatment of symptomatic uterine leiomyomas.

Number of embryos transferred and implantation

Multiple pregnancies are considered the most frequent and serious complication of assisted reproduction technology. To reduce the frequency of multiple pregnancies, several centers have adopted a policy of reducing the number of embryos transferred in the uterus, suggesting single embryo transfer. Even though a significant number of papers have been published on this issue, no general consensus exists on how many embryos to replace in the uterus and at which cleavage stage. We conducted a retrospective study on cycles performed throughout 2003, analyzing the relation between the number of embryos transferred and the pregnancy and implantation rates, evaluating also the role of the woman's age. No differences were found among the groups except in one-embryo transferred women, which were mostly natural cycles, for estradiol levels, number of mature oocytes retrieved, number of top quality embryos, and pregnancy rate. The implantation rate was significantly higher in the two-embryo transfers versus three-embryo transfers. We found higher pregnancy and implantation rates with similar multiple pregnancy rates in patients where only two embryos were transferred versus three embryos transfer when women were less than 35 years old. In women aged less than 35 years, which in turn have the higher expectancy of successful pregnancy and also the higher risk of multiple pregnancy, the single embryo transfer is a suitable choice for these patients.

Serum luteinizing hormone, follicle-stimulating hormone and oestradiol pattern in women undergoing pituitary suppression with different gonadotrophin-releasing hormone analogue protocols for assisted reproduction

Gonadotrophin-releasing hormone analogues (GnRH-a) are used widely in controlled ovarian stimulation (COS) cycles for assisted reproduction. At present, there is great debate about the influence of exogenous hormone activity on the hypothalamus-pituitary axis following pituitary desensitization. The objective of this comparative study was to investigate the pattern of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and oestradiol in women undergoing ovarian stimulation with different GnRH-a preparations. We retrospectively analysed 201 women, aged between 27 and 43 years, who were referred consecutively to our infertility clinic between January 2002 and January 2003. All women had no endocrinopathies or occult ovarian failure as assessed by day-3 hormone profile. Women were enrolled in one of the following COS protocols: depot triptorelin long protocol (n = 38), buserelin long protocol (n = 101) or buserelin short protocol (n = 62). Recombinant FSH was used to induce ovulation. Treatment was monitored by transvaginal ultrasound scan and serum measurement of FSH, LH and oestradiol. Among the women initially included, 30 had cancelled cycles due to poor ovarian response. Serum LH levels were significantly higher in the short-protocol group compared with the long-protocol groups (p < 0.001). The number of follicles, oocyte yield, number of grade-I embryos and fertilization rate were significantly lower in the short-protocol group than in the long-protocol groups. These findings showed that LH concentrations are significantly higher in women undergoing reversible medical hypophysectomy with a GnRH-a short protocol than in women treated with a long protocol. The hypothesis of an LH ceiling is confirmed.

Add-back therapy in the treatment of endometriosis-associated pain

OBJECTIVE

To determine the efficacy of GnRH analogue plus add-back therapy compared with GnRH analogue alone and estroprogestin in patients with relapse of endometriosis-associated pain.

DESIGN

Randomized, controlled study.

SETTING

University hospital.

PATIENT(S)

One hundred thirty-three women with relapse of endometriosis-related pain after previous endometriosis surgery.

INTERVENTION(S)

Forty-six women were treated with GnRH analogue plus add-back therapy, 44 women were given GnRH analogue alone, and 43 women received estroprogestin, for 12 months.

MAIN OUTCOME MEASURE(S)

Pain evaluation by a visual analogue scale, quality of life in treated patients according to the SF-36 questionnaire, and occurrence of adverse effects, including bone mass density loss, at pretreatment, after 6 months of treatment, at the end of treatment (12 months), and 6 months after discontinuation of treatment.

RESULT(S)

Patients treated either with GnRH analogue alone or GnRH analogue plus add-back therapy showed a higher reduction of pelvic pain, dysmenorrhea, and dyspareunia than patients treated with oral contraceptive, whereas patients treated with add-back therapy showed a better quality of life, as assessed with the SF-36 questionnaire, and adverse effects rate than the other two groups.

CONCLUSION(S)

Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period, with reduced bone mineral density loss, good control of pain symptoms, and better patient quality of life compared with GnRH analogue alone or oral contraceptive.

Immunohistochemical localization of the growth hormone in human endometrium and decidua

PROBLEM

Recent evidence of growth hormone (GH) receptor expression in rat endometrium and human myometrium have focused our attention on the role of the GH in endometrial development. We tested the expression of GH in the human endometrium throughout the menstrual cycle and during pregnancy.

METHOD OF STUDY

Immunohistochemical study was performed on endometrial specimens of fertile women in different periods of the menstrual cycle and in decidua of pregnant women.

RESULTS

Glandular cells of the human endometrium were positive for GH in the mid and late luteal phase. Furthermore, the glandular cells of decidua showed intense staining for GH, while the stromal cells were negative. No immunostaining was expressed in the proliferative or early luteal phase. The intensity levels of staining for GH in decidual specimens were significantly higher than in glandular cells of secretory endometrium specimens (P < 0.01).

CONCLUSIONS

The glandular cells of the human endometrium express GH from the late luteal phase throughout pregnancy in the decidual tissue. We suppose that GH plays an important role in blastocyst implantation.

A controlled trial of natural cycle versus microdose gonadotropin-releasing hormone analog flare cycles in poor responders undergoing in vitro fertilization

OBJECTIVE

To determine the efficacy of natural-cycle IVF compared with controlled ovarian hyperstimulation in poor responders.

DESIGN

Randomized, controlled study.

SETTING

Private center for assisted reproduction.

PATIENT(S)

One hundred twenty-nine women who were poor responders in a previous IVF cycle.

INTERVENTION(S)

Fifty-nine women underwent 114 attempts of natural-cycle IVF, and 70 women underwent 101 attempts of IVF with controlled ovarian hyperstimulation with microdose GnRH analog flare.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved, pregnancy rate (PR) per cycle, PR per transfer, and implantation rate.

RESULT(S)

The poor responders treated with natural-cycle IVF and those treated with micro-GnRH analog flare showed similar PRs per cycle and per transfer. The women treated with natural-cycle IVF showed a statistically significant higher implantation rate (14.9%) compared with controls (5.5%). When subdivided into three groups according to age (<or=35 years, >or=36-39 years, >or=40 years), younger patients had a better PR than the other two groups.

CONCLUSION(S)

In poor responders, natural-cycle IVF is at least as effective as controlled ovarian hyperstimulation, especially in younger patients, with a better implantation rate.