ivf & recurrent implantation failure · definition failure to achieve a clinical pregnancy...
TRANSCRIPT
IVF amp
Recurrent
Implantation Failure
Dr Kaberi Banerjee
Medical Director
Advance Fertility and Gynaecology Centre
New Delhi
Definition
Failure to achieve a clinical pregnancy after transfer of at least 4 good-
quality embryos in a minimum of 3 fresh or frozen cycles in a woman
under the age of 40 years
Failure of implantation after transfer of at least 4 good-quality embryos
or 2 blastocysts after transfer in 2 cycles
Failure could be caused by many different factors such
as
inappropriate ovarian stimulation
suboptimal laboratory culture conditions and
faults in embryo transfer techniques
These would usually result in a low pregnancy rate (PR)
for the whole unit
Factors
Embryo factors
Uterine factors
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Definition
Failure to achieve a clinical pregnancy after transfer of at least 4 good-
quality embryos in a minimum of 3 fresh or frozen cycles in a woman
under the age of 40 years
Failure of implantation after transfer of at least 4 good-quality embryos
or 2 blastocysts after transfer in 2 cycles
Failure could be caused by many different factors such
as
inappropriate ovarian stimulation
suboptimal laboratory culture conditions and
faults in embryo transfer techniques
These would usually result in a low pregnancy rate (PR)
for the whole unit
Factors
Embryo factors
Uterine factors
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Failure could be caused by many different factors such
as
inappropriate ovarian stimulation
suboptimal laboratory culture conditions and
faults in embryo transfer techniques
These would usually result in a low pregnancy rate (PR)
for the whole unit
Factors
Embryo factors
Uterine factors
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Factors
Embryo factors
Uterine factors
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Cleavage-stage embryos
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Day 5 assessment (Blastocyst
stage)
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Non-viable embryo
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Oocyte Scoring
Cumulus-oocyte complex scoring
Binary score (0 or 1)
lsquoGoodrsquo COC (score of 1) - expanded cumulus and a radiating corona
Zona pellucida scoring
Colour or thickness of the zona pellucida
Perivitelline space - Presence of inclusions
Polar body scoring
Presence or absence of the first polar body
Size of the polar body (Abnormally large polar body - risk of oocyte aneuploidy
Cytoplasm scoring ndash Check for lsquogranularityrsquo of cytoplasm
Vacuolization - Large vacuoles (gt14 microm in diameter) - fertilization failure
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Poor Oocyte Quality
Factors
Higher age group
Increased chromosomal
nondysjunction
Aneuploid embryos
Decrease in mitochondrial
membrane potential and increase
of mitochondrial DNA damage
High FSH low AMH and low AFC
Aggressive ovarian stimulation
protocols
Indicated by
Poor response to
ovarian stimulation
Retrieval of few
oocytes
High proportion of
immature oocytes
Reduced fertilization
rate
Low embryo utilization
rate
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sperm
Structure
DNA Fragmentation
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sperm Structural Defects
Infection
Kartageners
Globozoospermia
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sperm DNA fragmentation
Infection or inflammatory of genital
tract
Varicocele
Testicular maldescent
Impaired spermatogenesis
Radiotherapy or chemotherapy
Exposition to heat chemical products
Idiopathic
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sperm DNA fragmentation
Spermatozoa with fragmented DNA
le 15 ndash good fertility potential
15-25 - average
gt 25 - poor fertility potential
DFI gt 25-30 - direct IVFICSI
DFIgt 30 - ICSI considered
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Treatment
Life style changes
Quit smoking
Stop alcohol consumption
Weight loss (In case of body mass index gt29 kgm2)
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Treatment for Embryonic Factor
(To Improve Egg quality)
Age
Good stimulation drugs and protocols
DHEA
Arginine
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Treatment for Embryonic Factor
(To Improve Egg quality)
Ovarian stimulation protocol
Proper gonadotropin dose selection according to ovarian
reserve
Addition of LH (gt 35 years age)
Ultra-long protocol for endometriosis and adenomyosis
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Hum Reprod Update 2014 Jan-Feb20(1)124-40 doi
101093humupddmt037 Epub 2013 Sep 29
Individualization of controlled ovarian stimulation in IVF using
ovarian reserve markers from theory to practice
La Marca A1 Sunkara SK
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Strategic modelling of controlled ovarian hyperstimulation based on ovarian reserve markers
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Normogram for calculating starting dose of gonadotropins in COS
Le Marca and Sunkara 2012
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Treatment for Embryonic Factor
(To Improve Sperm quality)
Antibiotic treatment
Anti oxidants
Varicocele Surgery
ICSI
IMSI
PGS
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Treatment for Embryonic
Factor
Blastocyst transfer
Assisted hatching
Zygote intra-Fallopian
transfer
Metabolomics
Use of Embryoscope
Preimplantation genetic
screening
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Blastocyst Transfer
Chromosomally
competent embryos
develop to blastocyst
stage
Physiological
synchronization with
uterine endometrium
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Assisted Hatching
Artificial thinning or breaching of
zona pellucida
Laser Mechanical Chemical
Indications Thick Zona Advanced
Age Frozen cycles
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Zygote intra-Fallopian transfer
(ZIFT)
Advantage
Zygotes comes in contact with numerous growth factors
and cytokines in tubal fluid amp attain to the uterus with
greater synchronization
Disadvantages
Need for GA laparoscopy theatre time and surgical
equipment
Expensive procedure
Increased risk of ectopic gestation
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Embryo Metabolism
Predictor of reproductive potential
Pyruvate and lactate metabolism
Glucose metabolism
Amino acid metabolism
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Embryoscope - Time-lapse
analysis
Novel non-invasive method
Dynamic morphometric assessment
Monitor embryo development continuously
Allows precise measurement of 1st
cleavage time PN fading
Prevents from taking the dishes out of the
incubator
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Embryoscope
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Pre-implantation genetic
diagnosis (PGS)
Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
Genetic counselling
before procedure
To detect Chromosomal
normalcy
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
PGS indications
Recurrent miscarriages
Maternal age older than 38
Prior failure with IVF
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
PGS Method
Ovulation Induction with drugs
Egg Retrieval
Fertilization
Biopsy
Unfertilised and fertilised oocytes (for polar bodies PBs)
On day three cleavage-stage embryos (for blastomeres ndash Preferable)
On blastocysts (for trophectoderm cells)
Genetic Analysis (FISH PCRaCGH)
Comparative genomic hybridization (CGH) can promote detection of genetic abnormalities (deletions or excess of DNA content) across the genome
Embryo Transfer
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Challenges of PGS
Still evolving
Results conflicting
Need advanced culture systems
Need high skill
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Oocyte+Sperm(Embryo)+Uterus=
Implantation
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrium
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrial Receptivity
Depends upon
Uterine cavity
abnormalitiespatholog
ies
Endometrial thickness
Altered expression of
adhesive molecules
Immunological factors
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Uterine
abnormalitiespathologies
Uterine abnormalities
Hyperplasia
Polyps
Endometritis
Synechiae
Leiomyoma
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Investigations
(Uterine amp Other factors)
USG pelvis ndash 2 D 3 D
HSG SSG
Endoscopy
Hysteroscopy
Laparoscopy
Endometrial biopsy ndash Uterine NK cells TNF α
Endometrial Receptivity Array (ERA)
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrial Lining
Endometrial thickness
Endometrial volume
Endometrial pattern
Uterine artery blood flow
Endometrial subendometrial blood
flow
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Findings at Routine
Hysteroscopy
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Implantation ndash A Complex
Process
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Immunological factors
Natural Killer (NK) Cells ndash Uterine
Cytotoxic Lymphocytes (CTLs)
Antithyroid Antibodies (ATA)
Alloimmune Implantation Dysfunction
HLA compatibility HLA‐G and DQ‐alpha
Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
Autoimmune Response to Sperm
Antigen
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrial Receptivity Array
(ERA)
Genetic test to diagnose state of
endometrial receptivity in window of
implantation
Analyse expression levels of 238 genes
related to status of endometrial
receptivity
Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrial Receptivity Array
Endometrial biopsy ndash
Natural cycle at day 21 ie 7 days after LH surge
LH+7 or 6 days after the follicle rupture when
monitored by ultrasound)
Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
After biopsy - immediately introduced into an
ldquoERA cryotuberdquo containing fluid that allows
preservation of tissue
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Endometrial receptivity array
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Interpretation of results
(R) Receptive
Advised to proceed with ET in same conditions type of
cycle and day when EB has been done
(NR) Non Receptive
New EB to be taken to validate implantation window
displacement and guide ET
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Conclusion
ERA can be helpful in patients with RIF
Requirement of non invasive method of testing
Individualizes ET timing
Small numbers Retrospective
Further research required
Cost benefit requires work
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Improving Soil
Hysteroscopic correction of cavity pathology
Myomectomy
Treatment of thin endometrium (High-dose estrogens low-dose aspirin amp vaginal sildenafilarginine)
Endometrial stimulation (biopsy) -pseudo-decidual reaction
Immunotherapy (intravenous immunoglobulin steroids aspirin and heparin)
Anti ndash Tubercular Therapy
Treating Adenomyosis
Changing day of transfer
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Aspirin Study
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Heparin
MOA
Anticoagulant
Immunomodulatory
Anti-inflammatory
effect
Results in adhesion of
blastocyst to endometrial
epithelium and
subsequent invasion
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Prednisolone
MOA
Immunosuppression
uterine NK cells
Cytokines
Endometrialinflammation
Better implantation rate
Orally
10 mg once daily (Before breakfast
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sildenafil
MOA
Selective inhibitor of the type V
cGMP- specific phosphodiesterase
Vasodilatory effects of
nitric oxide
Uterine blood flow
Improved endometrial
thickness
25 mg once in night (Vaginally)
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
httpdxdoiorg101016jfertnstert201607956
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Consensus re ATT
AFB Pos
IGRA test + PCR Positive
Clinical doubt of TB
Interferon Gamma Release Assay
Nucleic Acid Amplification Test
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Other Factors
Hydrosalpinges
Embryo transfer techniques
Adjunctive treatment
(Metformin Bromocriptine
Thyroxine)
Alternative treatment
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Embryo ---------- Uterus The Missing Link
Embryo Transfer
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Improving ET technique
USG guided
Mock ET
Full bladder
Use of Stylet
Irrigation and aspiration of cervical mucus
Maximal Implantation Point
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Sequential Transfer
D2D3 and D5
Same Cycle
RIF
Freezing not option
Multiple Pregnancy
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Correct Cavity
Treat Hydrosalpinx
Hysteroscopy amp Endometrial Scratching
Improve Protocol
Delayed Transfer
IVIG
Assisted hatching
Sequential Transfer
LMWH
PGS
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Human Reproduction Vol21 No12 pp 3036ndash3043 2006 doi101093humrepdel305
Advance Access publication August 12 2006
3036 copy The Author 2006 Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology All rights reserved
For Permissions please email journalspermissionsoxfordjournalsorg
Mini ReviewmdashDevelopments in Reproductive Medicine
Investigation and treatment of repeated implantation failure following IVF-ET
EJMargalioth1 ABen-Chetrit MGal and TEldar-Geva
IVF Unit Shaare-Zedek Medical Center Ben Gurion University of the Negev Jerusalem Israel
1To whom correspondence should be addressed at IVF Unit Shaare-Zedek Medical Center PO Box 3235 Jerusalem 91031 Israel
E-mail ehudmdhotmailcom
Pregnancy rate following one cycle of IVF and ET can be as high as 60 But even in the very successful units some
couples fail repeatedly The causes for repeated implantation failure (RIF) may be because of reduced endometrial
receptivity embryonic defects or multifactorial causes Various uterine pathologies such as thin endometrium
altered expression of adhesive molecules and immunological factors may decrease endometrial receptivity whereas
genetic abnormalities of the male or female sperm defects embryonic aneuploidy or zona hardening are among the
embryonic reasons for failure of implantation Endometriosis and hydrosalpinges may adversely influence both In
this mini review we discuss the suggested methods for evaluation and treatment of RIF repeated hysteroscopy myo-
mectomy endometrial stimulation immunotherapy preimplantation genetic screening (PGS) assisted hatching
zygote intra-Fallopian transfer (ZIFT) co-culture blastocyst transfer cytoplasmic transfer tailoring stimulation
protocols and salpingectomy for hydrosalpinges
Key words implantationIVF failureIVF treatmentrepeated failure
Introduction
Treatment of infertile couples has progressed immensely dur-
ing recent years From close to 235000 registered assisted
reproductive technology (ART) cycles performed in Europe
during the year 2001 nearly 29 resulted in a pregnancy
(Andersen et al 2005) Failure could be caused by many dif-
ferent factors such as inappropriate ovarian stimulation subop-
timal laboratory culture conditions and faults in embryo
transfer techniques These would usually result in a low preg-
nancy rate (PR) for the whole unit But even in successful units
with high pregnancy and delivery rates some couples have
repeated implantation failure (RIF) The aim of this article is to
summarize the reported aetiologies for RIF highlight the sug-
gested investigations to be performed and review the recom-
mended treatment strategies
Definition of RIF
Failure to achieve a pregnancy following 2ndash6 IVF cycles in
which more than 10 high-grade embryos were transferred to
the uterus was defined by various clinicians as RIF (Tan et al
2005) Today with the tendency of transferring only one or two
embryos the definition of RIF is not apparent Nevertheless
we suggest that after failure of three cycles in which reasonably
good embryos were transferred further investigation should be
initiated
Assumed aetiologies for RIF
Embryonic loss which occurs repeatedly after assisted repro-
duction may be attributed to many factors These can be grouped
into three categories decreased endometrial receptivity embry-
onic defects and factors with combined effect (Table I)
Decreased endometrial receptivity
RIF might be because of undiagnosed uterine pathology In
18ndash27 of women with a normal initial hysteroscopy or hyste-
rosalpingogram repeated hysteroscopic visualization after RIF
revealed uterine abnormalities mainly hyperplasia polyps
endometritis synechiae and leiomyomata (Demirol and Gur-
gan 2004) The effect of leiomyomata on implantation is
uncertain (review Surrey 2003) Specifically the impacts of
intramural lesions without cavity distortion (Eldar-Geva et al
1998) or myomas of lt4 cm (Oliveira et al 2004) on RIF
remain controversial
The presence of a thin endometrium did not influence the
cumulative PRs in a prospective large cohort studies (De Geyter
et al 2000) particularly when high-quality embryos were
transferred (Zhang et al 2005) Thin or hyperechogenic
endometrium or persistent endometrial fluid impaired the out-
come in tubal factor but not in polycystic ovary syndrome
(PCOS) (Akman et al 2005) or ICSI (Rinaldi et al 1996)
However the concept that a minimum thickness (4ndash8 mm) is
Thank you
Thank you
