Markers of endometrial receptivity: a study of ultrasonographic and molecular factors

The evidence suggests that alteration of the endometrial environment in women with previous failed in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) by inflicting endometrial injury improves the outcome of the subsequent treatment cycle. The selected population assessed in the studies supporting this statement prevents from generalizing this to all women undergoing IVF or ICSI treatment. The mechanisms responsible for alteration of the endometrial environment following biopsy remain still unclear. If proven effective, endometrial injury could serve as a beneficial adjunct for all couples undergoing assisted reproductive treatment (ART). The hypothesis forming the basis of the work reported in this thesis was that endometrial injury in the cycle directly preceding an embryo transfer cycle, be it fresh or frozen, improves the outcome of that treatment irrespective of previous reproductive history. In order to support or refute this hypothesis, a clinical trial of endometrial biopsy prior to IVF or ICSI treatment has been designed. Additional objectives that allow examining the mechanisms responsible for the beneficial effects of the biopsy on the endometrium included utilization of two-dimensional, three- dimensional and Spatio-Temporal Image Correlation (STIC) ultrasound and assessment of the predictive value of any sonographic indices on ART outcome. Same sonographic modalities were used to determine the effect of endometrial injury on endometrial and subendometrial blood flow. Similarly, an examination of the value of uterine natural killer (uNK) cell numbers and expression of selected molecular markers of endometrial function as a predictors of ART outcome was explored. In this work it was not possible to clearly demonstrate a benefit of routine endometrial biopsy in all women undergoing ART on treatment outcomes, though clues, as to which population might benefit from the procedure, were identified. Extensive sonographic analysis of endometrial factors did not produce results allowing for unequivocal non- invasive identification of a receptive endometrial milieu. Triple layer endometrial pattern at oocyte collection was correlated with positive outcome and endometrial biopsy. Spatio-Temporal Image Correlation did not fulfil expectations as a non-invasive marker of endometrial receptivity and was not able to identify women that would go on to have a successful ART outcome. In a small number of patients, STIC indices were able to predict first trimester miscarriage with relatively high sensitivity and specificity. uNK cell numbers were not associated nor predictive of ART outcome, and as such not useful as a routine diagnostic tests prior to ART. An observed significant decrease in uNK cell levels following endometrial biopsy indicates a possible mechanism of action of this intervention. Limited (3) molecular cues were not able to differentiate between a receptive and non-receptive endometrium. This work, however extensive, indicates that the endometrium is a complex microenvironment requiring further investigation in order to understand and influence the mechanisms related to pregnancy establishment and development

Deregulation of the endometrial stromal cell secretome precedes embryo implantation failure

STUDY QUESTION Is implantation failure following ART associated with a perturbed decidual response in endometrial stromal cells (EnSCs)? SUMMARY ANSWER Dynamic changes in the secretome of decidualizing EnSCs underpin the transition of a hostile to a supportive endometrial microenvironment for embryo implantation; perturbation in this transitional pathway prior to ART is associated with implantation failure. WHAT IS KNOWN ALREADY Implantation is the rate-limiting step in ART, although the contribution of an aberrant endometrial microenvironment in IVF failure remains ill defined. STUDY DESIGN, SIZE, DURATION In vitro characterization of the temporal changes in the decidual response of primary EnSCs isolated prior to a successful or failed ART cycle. An analysis of embryo responses to secreted cues from undifferentiated and decidualizing EnSCs was performed. The primary clinical outcome of the study was a positive urinary pregnancy test 14 days after embryo transfer. PARTICIPANTS/MATERIALS, SETTING, METHODS Primary EnSCs were isolated from endometrial biopsies obtained prior to IVF treatment and cryopreserved. EnSCs from 10 pregnant and 10 non-pregnant patients were then thawed, expanded in culture, subjected to clonogenic assays, and decidualized for either 2 or 8 days. Transcript levels of decidual marker gene [prolactin (PRL), insulin-like growth factor binding protein 1 (IGFBP1) and 11β-hydroxysteroid dehydrogenase (HSD11B1)] were analysed using real-time quantitative PCR and temporal secretome changes of 45 cytokines, chemokines and growth factors were measured by multiplex suspension bead immunoassay. The impact of the EnSC secretome on human blastocyst development was scored morphologically; and embryo secretions in response to EnSC cues analyzed by multiplex suspension bead immunoassay. MAIN RESULTS AND THE ROLE OF CHANCE Clonogenicity and induction of decidual marker genes were comparable between EnSC cultures from pregnant and non-pregnant group groups (P > 0.05). Analysis of 23 secreted factors revealed that successful implantation was associated with co-ordinated secretome changes in decidualizing EnSCs, which were most pronounced on Day 2 of differentiation: 17 differentially secreted proteins on Day 2 of decidualization relative to undifferentiated (Day 0) EnSCs (P 0.05)

Markers of endometrial receptivity: a study of ultrasonographic and molecular factors

The evidence suggests that alteration of the endometrial environment in women with previous failed in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) by inflicting endometrial injury improves the outcome of the subsequent treatment cycle. The selected population assessed in the studies supporting this statement prevents from generalizing this to all women undergoing IVF or ICSI treatment. The mechanisms responsible for alteration of the endometrial environment following biopsy remain still unclear. If proven effective, endometrial injury could serve as a beneficial adjunct for all couples undergoing assisted reproductive treatment (ART). The hypothesis forming the basis of the work reported in this thesis was that endometrial injury in the cycle directly preceding an embryo transfer cycle, be it fresh or frozen, improves the outcome of that treatment irrespective of previous reproductive history. In order to support or refute this hypothesis, a clinical trial of endometrial biopsy prior to IVF or ICSI treatment has been designed. Additional objectives that allow examining the mechanisms responsible for the beneficial effects of the biopsy on the endometrium included utilization of two-dimensional, three- dimensional and Spatio-Temporal Image Correlation (STIC) ultrasound and assessment of the predictive value of any sonographic indices on ART outcome. Same sonographic modalities were used to determine the effect of endometrial injury on endometrial and subendometrial blood flow. Similarly, an examination of the value of uterine natural killer (uNK) cell numbers and expression of selected molecular markers of endometrial function as a predictors of ART outcome was explored. In this work it was not possible to clearly demonstrate a benefit of routine endometrial biopsy in all women undergoing ART on treatment outcomes, though clues, as to which population might benefit from the procedure, were identified. Extensive sonographic analysis of endometrial factors did not produce results allowing for unequivocal non- invasive identification of a receptive endometrial milieu. Triple layer endometrial pattern at oocyte collection was correlated with positive outcome and endometrial biopsy. Spatio-Temporal Image Correlation did not fulfil expectations as a non-invasive marker of endometrial receptivity and was not able to identify women that would go on to have a successful ART outcome. In a small number of patients, STIC indices were able to predict first trimester miscarriage with relatively high sensitivity and specificity. uNK cell numbers were not associated nor predictive of ART outcome, and as such not useful as a routine diagnostic tests prior to ART. An observed significant decrease in uNK cell levels following endometrial biopsy indicates a possible mechanism of action of this intervention. Limited (3) molecular cues were not able to differentiate between a receptive and non-receptive endometrium. This work, however extensive, indicates that the endometrium is a complex microenvironment requiring further investigation in order to understand and influence the mechanisms related to pregnancy establishment and development

Primary amyloidosis presenting as cholestatic jaundice

This case report describes a rare but fatal presentation of amyloidosis. Multiple organs and systems can be affected by the condition. Cholestatic jaundice is a infrequent manifestation of amyloidosis. An 80-year-old patient died within a month after onset of jaundice as a result of irreversible damage caused by deposition of amyloid. The relatively short period of time did not allow a tissue sample to be obtained from the patient and the final diagnosis was made postmortem

What exactly do we mean by ‘recurrent implantation failure’? A systematic review and opinion

Recurrent implantation failure (RIF) is an iatrogenic condition, being the result of repetitive unsuccessful cycles of IVF or intracytoplasmic sperm injection (ICSI) treatment. The aim of this review was to assess the definitions of RIF used in literature as well as suggest a uniform definition of this condition. A systematic search of MEDLINE, Embase and Cochrane Library was conducted. The most commonly stated definitions described RIF as ‘three or more failed treatment cycles’ or ‘two or more failed cycles’. Other identified definitions were based solely on the number of embryos transferred in previous cycles or combined the number of previously failed cycles with the number of transferred embryos. Several other definitions were also identified. This review highlights the lack of uniformity of the definition of RIF. Based on the available literature and the expert opinion of the authors, RIF should be defined as the absence of implantation after two consecutive cycles of IVF, ICSI or frozen embryo replacement cycles where the cumulative number of transferred embryos was no less than four for cleavage-stage embryos and no less than two for blastocysts, with all embryos being of good quality and of appropriate developmental stage. Recurrent implantation failure (RIF) is a condition resulting from repetitive unsuccessful cycles of IVF or intracytoplasmic sperm injection (ICSI) treatment. The aim of this review was to assess the definitions of RIF used in literature as well as suggest a uniform definition of this condition. A systematic search of MEDLINE, Embase and Cochrane Library was conducted. The most commonly stated definitions described RIF as ‘three or more failed treatment IVF or ICSI cycles’ or ‘two or more’ failed cycles. Other identified definitions were based only on the number of embryos transferred in previous cycles or combined the number of previously failed cycles with the number of transferred embryos. This review highlights the lack of consistency of the definition of recurrent implantation failure. Based on the available literature and the expert opinion of the authors, RIF should be defined as the absence of attachment of the embryo to the lining of the womb after two consecutive cycles of IVF, ICSI or frozen embryo replacement cycles where the cumulative number of transferred embryos was no less than four for day-2 embryos and no less than 2 for day-5 embryos (blastocysts), with all embryos being of good quality and of appropriate developmental stage. We hope that adopting a standard definition will allow for good-quality research to be conducted into this distressing condition preventing couples from having offspring

Interventions to improve reproductive outcomes in women with elevated natural killer cells undergoing assisted reproduction techniques : a systematic review of literature

Study question Is there any scientific evidence to support the routine use of adjuvant therapies for women with elevated natural killer (NK) cells undergoing assisted reproduction techniques (ARTs) in order to improve live birth rate? Summary answer Due to the poor quality evidence, this review does not support the use of described adjuvant treatments in women found to have elevated absolute numbers or activity of NK cells undergoing ART. What is known already Deregulation in the numbers of NK cells and/or their activity, in the blood as well as in the endometrium, has been associated with various manifestations of reproductive failure. NK cell analysis is becoming increasingly popular as a test offered to investigate the causes of reproductive failure. Adjuvant therapies influencing the NK cells have been postulated as therapeutic options for couples where deregulation of this component of the maternal immune system is suspected as the cause of infertility or implantation failure. Study design, size, duration Systematic review. Embase, LILACS, MEDLINE, PsycINFO, CENTRAL and CINAHL databases from 1946 to present were searched with no language restrictions. Participants/materials, setting, methods Studies evaluating the use of adjuvant therapies in women undergoing ART where NK cell numbers and/or activity were assessed were considered eligible for inclusion. Main results and the role of chance Only three studies (one in abstract form only) meeting the inclusion criteria were identified: two reported the use of intravenous immunoglobulins (IVIg) and one the use of oral prednisolone. All studies demonstrated a beneficial effect of the interventions on clinical pregnancy rates with a risk ratio (RR) of 1.63 [95% confidence interval (CI) 1.00–2.66] for prednisolone and 3.41 (95%CI 1.90–6.11) for IVIg. Studies assessing the efficacy of IVIg have also reported live birth rate with an RR of 3.94 (95% CI 2.01–7.69) favoring the intervention. Data heterogeneity was substantial however (I2 = 66%) suggesting a cautious interpretation of the results. Limitations, reasons for caution Differing study populations, lack of statistical power, method of data presentation (per couple or per cycle), the use of additional medications and differing dosage regimes contribute to data heterogeneity and suggest a cautious approach to data interpretation. Wider implications of the findings This review identified some data showing that adjuvant therapies (mainly IVIg) in this selected population seem to confer some benefit on ART outcome. However, overall, the review does not support the use of prednisolone, IVIg or any other adjuvant treatment in women undergoing ART who are found to have elevated absolute numbers or activity of NK cells, purely due to the paucity of, or poor quality of, the evidence. Agreement as to the most reliable NK cell testing method must be made by the scientific community as well as ‘normal’ NK cell levels unequivocally defined. Well designed, sufficiently powered RCTs with an appropriate population selection and using the same NK cell testing methodology are required to ascertain the actual benefit of using adjuvant therapy treatment for elevated NK cell levels or activity in the context of pregnancy outcome following IVF. Study funding/competing interest(s) None

Second asymptomatic carotid surgery trial (ACST-2) : a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable