Habitual implantation failure /RM,RIF/

1
Habitual implantation failure /RM,RIF/

• S. Škrablin

2
Successful implantation

• Materno-fetal dialogue
• Competent blastocyst
• receptive endometrium

3
Window of implantation
Th1 phenomenon

• 19-23 cycle day (6. day after ovulation!!!)
• Stromal cells transformation into decidual cells
  secretory granules, pinopodes, disappearance of
  mycrovilli
• Cytokines, chemokines, ligands.
• dNK, macrophages, uDCs

Regulatory role in trophoblast invasion
APC antigen presenting cells
Angiogenesis, decidualisation
4
LIF and p53 (Stewart LC, Nature 2007 450619,
Hu W et al. Nature 2007 450721)
HCG LIF
LIF receptor interraction endometrial
receptivity
Acquisition of adhaesion ligands and loss of
inhibitory molecules
5
HOX gens
Segmental body identity

• HOX gens endometrial development
• - steroid hormones
  function
• - elevated expression
  during secretory phase
• - with successful
  implantation increased
  decidual expression
• - regulation of
  morphological parameters of implantation window
  pinopodes, beta 3 integrin, IGFBP1
• - essential for
  implantation low HOX genes expression during
  the secretory phase - infertility /Taylor et
  al.1999, Rackow and Taylor 2010/

unexplained infertility /Brosens et al., 2009/
6
HOX expression manipulation- increased
implantation with EAI /in vitro / /Bagot et
al., 2000/
7
Implantation failure/Cakmak H, Taylor HS. 2011/

• Leiomyoma
• deformity
• occlusion
• Low HOXA10 and BTEB1 exp.
• PCOS
• Decreased avß3 integrin, HOXA-10 and IGFBP-1
• Overexpression of androgene receptors
• Absence of estrogen receptor-a downregulation
  during implantation window
• Overexpression of steroid receptor coactivators
  - AIB1 and TIF2

• Endometrial polyp
• Gamete transport
• Decreased IGFBP-1 i osteopontin
• Low progesteron receptors

8
Implantation failure /Cakmak H, Taylor HS. 2011/

• Endometriosis
• - Decreased avß3 integrins and LIF
• - Low IL-11 and IL-11R
• - Absence of HOXA10 and HOXA11 increase
• - Elevated EMX2
• - Progesteron resistence
• - Disregulation of PR-A / PR-B
• - HOX 10 promotor hypermetilation

• Hydrosalpinx
• Toxic effect of tubal secretions
• Decrease of avß3 integrin and LIF-a
• Low HOXA10 expression
• Septum, arcuatus
• Sy Asherman
• Thin endometrium
• Ovarian stimulation
• Adiposity
• Trombophilia
• Impaired endometrial function
• Immunologic factors

9
ENDOMETRIOSIS
10
Hox10/HOX10 geni ECTOPIC AND EUTOPIC
ENDOMETRIUM /Zanatta et. al., 2010/
Hoxa 9-tubes Hoxa 11-cervix Hoxa 13-vagina
Mulleriosis 11 female fetuses !!!!!!
HOX10-epithelial, stromal and myometrial
embriogenesis Expression is regulated by
cyclical E/P variation Endometrial receptivity
and nidation window

• Embrional remnants regrowth during and after
  puberty
• De novo creation of eutopic or ectopic
  endometrium when, why, what is the initial
  stimulus ????

11
EAI /Zanatta et. Al., 2010/
In 50 no alfa 5 beta 3 integrin - Infertile
with mild endometriosis /M. Donaghay, B.A. Lessey
2007/
Low FC, abnormal follicular maturation, Low
oocyte quality /Toya et al. 2000/

• Low endometrial alfa, beta integrin
• No IL -11 i IL 11R i LIF-a
• After GNRH analogues or ablation
• increased HOX expression and
• integrins
• /Lessey i Young 1997, Daftary et al., 2007/

• - Poor oocyte quality
• - Implantation failure

Ectopic towards eutopic endometrium -
communication ? Could radical surgery of
ectopic endometrium assure normal eutopic
edometrium function
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Molecular differences

• Ectopic
• 17beta-hydroxsteroid d., aromatase, P
  rec., ERbeta 140x
• P rezistence
• apoA-I plasma, endometrium, HCG resistant
  /beta HCG can not inhibit apo A-I/Brosens et al.,
  2009/

hallmark of e.
Medical od radical surgical silencing of
extrauterine genes could PREVENT e. Radical
surgery of e.foci DOUBLED success in ART cycles
/Bianchi et al., 2009/
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HYDROSALPINXENDOMETRITIS CHR
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PID , hydrosalpinx /Chukwuemeka et al, 2002/

• Chl. inf. , PID
• endometritis
• HSP- scar tissue
• - anti Chl HSP IgA marker for unsuccessful
  IVF
• - HSP 10 tubal infertility
• - HSP 60- early misccariage

• Hydrosalpinx
• ?Flushing effect, pinopod malfunction,
  malfunction of endometrial epitelial cells.
• ?Embriotoxic /animal studies/
• ?Out of phase endometrium low integrins , LIF,
  HOX

IVF success after salpingectomy / Strandel et
al., 2001, Cochrane dtb2002 /
15
FIBROIDS
16
IVF/ICSI meta analysis /Bajekal , Li 2000/

• Compared to infertile
• SM decreased fertility
• /RR PR 0,30/
• /Somigliana et al. 2011/

Similar results 3 META ANALYSES Pritts et al,
2009 Sunkara et al, 2010 Metwally et al, 2011.
P lt0,05
17
The effect of submucous fibroids /Rackow and
Taylor, 2010/

• Decreased HOXA10, HOXA11, LIF, BTEB1
• MRNA HOXA 10 i HOXA 11
  compared to intramural
• Global entire endometrium, not only beneath
  myoma
• Size of myoma not important!!!!!

Glycodelin, IL-10 only with SM /Ben-Nagi J et
al., 2010/
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Inflammatory reaction with fibroids/Miura S et
al., 2006/

• Monocyte chemotactic protein (MCP-1),
  macrophage infiltration, PGF2alfa - SM and IM
  sigg. elevated compared to SSM, healthy
  myometrium or endometrium
• Size of myoma not important!!!!!

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The outcome of pregnancy with fibroidsUniv. Med.
School Zagreb 2008-2012, N135mean age 35,4 y.
Skrablin et al. Eur J Obstet Gynecol Reprod Biol.
2005118(1)115-6.
Ap.1.9,1 Ap.2.9,4 pH 7,26

• 17 previous myomectomy17,6
• 35 previous delivery 25, 9
• 84 first pregnancy 62, 2
• 22 previous misccariage 16, 2
• IVF 9 (6,6)

Vaginal delivery 39 (28, 8) Complications 6
(4, 4) Ruptura uteri completa 1 Hysterectomia
abd. 5
N newborns gt22 tj 134 (1 triplets , 1
twins) Perinatal mortality 1/134 7,4o 23
weeks, Apgar 1/0
20
The ooutcome of pregnancy after myomectomy Univ.
Med. school Zagreb 2008-2012, N50mean age 35,9
y.
Skrablin et al.. Successful pregnancy after
spontaneous rupture of scarred uterus following
fundal myomectomy. Eur J Obstet Gynecol Reprod
Biol. 2005121(2)251-2
N 52 newborns (3 twins) Perinatal
mortality 3/52 57,6o (26 gemin 31 ruptura 32
IUGR)

• 15 previous birth 30,0
• 27 first pregnancy 54,0
• 9 previous miscarriage 18,0
• 3 IVF 6

Technique 18 lap 36,0 26 LPSC 52,0 2 Hys
4 1 sc 2 1 conversion lpsc to lap 2 2?
Ap.1.8,7 Ap.29,1 pH 7,16
Vaginal birth 4 Complications 1 (2,
0) Ruptura uteri completa 1 (31 tj., mors fetus
in grav)
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The effect of myomectomy
SM

• PCT spontaneous pregnancies
• - 15 increase in fertility, outcome of
  pregnancy unknown /Casini ML et al., 2006/
• - 10 reports risk of complications after
  myomectomy can not be determined with certainty
• /Viswanathan et al., 2007/

22
The effect of myomectomy randomized matched
controlstudy/Shokeir T, et al. 2010/
SM
Hys miomectomy N 101
Hys biopsy N103
63,4
28,2
pregnancy
Success with op. with type O and I, but NOT with
myoma type II
23
The effect of myomectomy /Pritts EA, Parker WH,
Olive DL, 2009/
IM

• IM N RR
  p
• (studies)
• CPR 2 3,76
  n.s.
• LBR 1 1,67
  n.s.
• SA 1 0,76
  n.s.

..as yet no data to support myomectomy in the
treatment of IM myomas to improve fertility
outcome
24
Tulandi, Barbieri, Falk, Uptodate 2011

• Asymptomatic leiomyomas
• - Suggestion not to postpone pregnancy,
  since leiomyomas, combined with advanced maternal
  age, may impair fertility and adversely impact
  pregnancy (Grade 2C)
• - Suggestion not to perform prophylactic
  myomectomy to prevent pregnancy
  complications (Grade 2C)
• Infertile or a history of recurrent pregnancy
  loss
• - Submucosal or an intracavitary component
  - myomectomy (Grade 2C).
• - Subserosal - against myomectomy (Grade
  2C).
• - Intramural fibroids that do not distort
  the uterine cavity, other sources of infertility
  should be addressed. The decision to perform a
  myomectomy should be made based on patient
  preference and clinical factors (eg, obstructing
  of a fallopian tube or the cervical canal or
  failure of other infertility treatments).
• IVF
• Submucosal fibroid or an intramural fibroid that
  deforms the uterine cavity should be removed
  (Grade 2C).

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ENDOMETRIAL POLYP
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Implantation with endometrial polyp

• Low IGFBP1 and osteopontin
• Low P receptor expression P resistency
• After polypectomy elevation of IGFBP1,
  osteopontin levels /Ben-Nagy et al., 2009/

27
The effect of polypectomy in subfertile women
S - IVF/ICSI/IUI Polipectomy C -IVF/ICSI/IUI
Without polipectomy

• Polyps
• - prior to IVF
• should be removed
• during the course of COH-
• management individualized
• /Afifi K, et al., 2010/

The only randomized
Perez-Medina et al.2005 IUI randomizirana
Lass et al.1999
Isikoglu et al.2006
28
Septum uteri /Revel, 2012/

• Blood flow dearranged
• UTERUS ARCUATUS - less than 1 cm, - probably
  without ill effect
• Hys - simple
• Still dubious whether to perform op. before
  conception
• Peer opinion poll in support of prophylactic
  operation less than 50 of experts!!!! /M.J.
  Cohen, T.S. Rosenzweig, A. Revel, 2007/

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Asherman Sy

• Sperm transport or implantation compromised
• Infertility in 802 / 2151 (43)- depending on
  severity
• PR no
  operation 51 (540 of 1052),
  - no therapy 46 (133 of 292)
• - Hys 74
  (468 of 632)
• /J.G.
  Schenker, E.J. Margalioth 1982/
• After surgery IUD ili baloons
• Bone marrow stem cells - regeneration /H.S.
  Taylor 2004/

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Thin endometrium

• Problem elevated oxygen in endometrium /R.F.
  Casper 2011/
• But, implantation could be successful even with
  very thin endometrium /3.7 mm/J.H. Check, R.
  Cohen 2011/
• 3D endometrial volum compared to 2D endometrial
  thickness - not better for IVF success
  estimation /J. Alcazar 2006/

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Ovarian stimulation

• E elevation endometrial receptivivity
  decreased
• CPR per transfer sigg. better after transfer of
  frozen embria /B.S. Shapiro et al., 2011/

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PCOS
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PCOS

• Oligoovulation
• P low and its regulatory function dearranged,
  constant unopposed E2
• Low alfa and beta integrin, HOX-10 i IGFBP1
  during secretory phase even in those with
  ovulations
• Elevated androgens - decreased HOX 10 expression
  
• Elevated A receptors, no downregulatiom Ealfa
  receptors

Low receptivity and steroid receptor
disregulation The consequence of low P or
insulin/androgen imbalance? /Cakmak H, Taylor HS,
2011/
34
ENDOMETRAL EVALUATION

• Clinical
• US thicknes and texture - 6mm
• No correlation with hystology
• Proliferative phase defect
• Subendometrial blood flow no correlation with
  implantation success or failure
• SHG
• In general capability of US methods to
  estimate implantation is low /Cakmak H i Taylor
  Hs, 2011/
• Hys

• PHD
• Endometrial dating no criteria for window of
  implantation
• Difficult and unpredictable in stimulated cycles
• Cannot differentiate fertile from infertile
  population /Coutifaris i sur. 2004/
• Markers
• - p53 /Goodman et al., 2009/
• - gene profiling /microarray/ or proteomic
  analysis- apoA-I /Brosens et al., 2011/
• - alfa, beta integrin, mucin, LIF, HOXA10,
  endometrial function test-EFT ..still
  experimental /Dubowy i sur. 2003/
• - trombophilia

MRI-junctional zone
35
LIF and IL 11

• Uterine flushings
• - LIF levels - estimation of successful
  implantation in IVF /Makkar et al., 2006/
• - low levels in infertile women /Delage
  et al., 1995/
• - LH 2 can predict IVF success in the
  next cycle /Mikolajzyk et al. 2007/
• FUTURE estrimation of endometrial function
  before aspiration
• IL 11mRNA - low levels in trophoblast and plasma
  in anembrionic gestation or miscarriage
  /Koumantaki et al., 2001/

Therapy??? /Brinsden et al 2009/
36
Treatment - today

• Endometriosis
• Fibroid
• Polyp
• Hydrosalpinx
• PCOS
• Adenomyosis
• Endometritis
• Trombophilia

• - Ablation, GNRH agonists
• - Miomectomy
• - Polypectomy
• - Salpingectomy or tubal
• occlusion
• - Weight loss, metformin
• - GNRH agonists, surgery
• -Antibiotics
• - LMWH

Heparin, aspirin vaskularization Cortikosteroids
immunological tolerance LIF, progesteron
receptivity IG immunologic tolerance
37
Treatment tomorrow.

• Reproductive surgery
• Endometrial scratching /Barash A et al., 2003/
• Priming - locally instilation or parenteral
  granulocyte colony-stimulating factor, HCG or
  piroxicam /N. Gleicher et al., 2011, R. Mansour
  et al., 2011, H.S. Moon et al., 2004/
• Stem cells /Taylor HS, 2004, Du H, Taylor
  HS,2010/
• Heparin, metformin stimulation of gene
  expression in endometrium /Germeyer et al., 2011/
• Embryo culture with adhaesion promoting factors (
  hyaluronic acid, heparanase, VEGF) / Revel et
  al., 2005, Hannan NJ et al., 2011/
• PIF /Duzy K., et al., 2011/
• ..

Leukonorm Lenograstim .
Gene improvement
Immunomodulation