Can

Endometrial  Sractch/Injury

Improve Implantation ?

Prof.Timur Gürgan MD Gürgan Women’s Health,Infertility anf IVF Center

Ankara,Turkey

 

§  a  recep've  endometrium    

§  a  normal  and  func'onal  embryo  at  the  blastocyst  developmental  stage    

§  a  synchronized  dialogue  between  maternal  and  embryonic  'ssues                        

                           Simon et al 2000

 

 

       Successful  implanta8on  requires:  

E8ology  of  Implanta8on  Failure  

§  Embryo              Chromosomal  abnormality  

       Low  quality  

§  Endometrial  recep'vity          Immune  Factors    

         Endometriosis  

           Hydrosalpinx  

           Leiomyomas,              Adenomyosis,            PCOS,  

           Polyps,  endometri's  ..  

Immune  system  

&  

Implanta8on  

Inflamation and Pregnancy

•  During normal pregnancy ,the human decidua contains high number

of immune cels such as macrophages,natural killer (NK)

cells,regulatory T cells. And dentritic cells which infiltrate the

decidua and accumulated around the inviding trophoblasts cells

•  The presence of immune cells at the implantation site is not associated with response to the foreign fetus but is attracted to

faciliated and protect the pregnancy

•  Implantation,placentation and first and early trimester of pregnancy

resemble ’an open wound ‘ that requires a strong inflamatory

response (apposition,attachement and invasion)

•  Epithelial and stromal changes (decidualisation and pinopode

formation /window of implantation )

•  Modulation of different gene expressions of different

cytokines,chemokines,growth factors and adhesion molecules

The role of immune system at the impaltation site

•  High level of the proinflamatory T helper cells (Th-1) and cytokines

(IL-6,Il-8,TNF alpha charecterize) early implantation

•  Cytokines secreted by the endometrial cells and by the cells of immune system that are recuited to the site of implantation

•  NK cells : regulates trophoblast invasion, sectretes angiogenic

factors to induce vascular growth and decidualisation,

•  Macrophages:

*Pivotal role on cytokine balancing at the maternal-fetal interface.

*Essential for successful decidualisation

*Plays central role in the process of tissue renewal and differentiation

•  Dentritic cells : Initiate and coordinate the innate immune adaptive

immune response and also support the effect of macrophages

Possible regulatory mechanisms for embryo-maternal cross- talk by immune system and endocrine systems

•  Periferally circulating immune cells act on the reproductive organs to

facilatate embryo implantation Fujiwara,2006

•  Peripheral immune /peripheral blood mononuclear cells(PBMC) cells in early pregnancy situmulate the corpus luteum function

•  PBMC transmit the information presence of an embryo to various organs

throughout the body including the uterus and maternal vessels in order to

prepare and maintain the implantation Hashi ,1998

•  PBMC promote endometrial cell receptivity Hosaka 2003

•  hCG alters PBMC function to facilitate embryo invasion Kosaka,2002

•  İmmune cells can induce early endometrial differentiation required for

subsequent implantation

•  Succesful allopregnancy is a Th2 phenomenon in local balance in between Th1 and Th2 environment Chaoulat,2002

•  Regulatory T cells and NK cells play impotatnt role in immune tolarence

and placentation and angiogenesis Hanna,2006;Saito,2008

 

Immune  and  endocrine  system  

&  

Implanta8on  

Successful  Implanta8on  &  RIF  

Embryological  and  Endometrial    Factors  for  RIF  Cytokines  Associated  with  Reproduc8on  

Koot  et.  al.,  2012.  Biochem.  Biophys.  A.  

Makrigiannakis  et.  al.,  2011.  J.  Reprod.  Immun.  

Impaired  recep8vity  and  Implanta8onin  women  with  

endometriosis,adeneomyosis  and  PCOS    

•  Abnormally expression of endometrial receptivity biomarkers

PCOS Endometriosis ,Adenomyosis

•  Integrins (αVβ3 integrin)

•  Selectin

•  Cadherin

•  Glycodelin

•  Osteopontin

•  MUC1

•  HOXA-10

•  IGFBP-1

•  NK cell activity

•  Appoptosis

Endometrial Stimuli & Implantation

•  Endometrial receptivity or the ‘window of

implantation’ is dependent on certain stimuli

Mechanical stimuli may activate the implantation :

•  Endometrial biopsy

•  Endometrial sctrach

•  Endometrial injury

•  Hysteroscopic approach

           CONFUSIONS  

 

§  Type  of  injury  (biopsi/injury)  

§  Instrumenta8on(  cureUe/  pipelle/hysteroscopy)  

§         Degree  of  injury  (endometrium/myometrium)  

§         Number  of  injury  

§         Localiza8on  of  injury  

§         Day  /phase  of    menstruel  cycle  

§         Time  between  endometrial  injury  and  embryo  transfer  cycle  

§         Unselected  popula8on  or  previous  failures  

Early  prolifera8ve  phase    

Demirol  and  Gurgan  2004  

Magrakis  et  al  2009  

Rama  Raju  et  al  2006  

 

Early  prolifera8ve  and  luteal  phases  

Barash  et  al  2003  

Narvekar  et  al  2010  

 

Luteal  phase  

Karimzadeh  et  al  2009  

Raziel  et  al  2007  

 

Once                            

 Zhou  et  al,  2008    

 Shohayep  &  El-­‐Khayat  2012  

 Coughlan  et  al,    2013    

 

Twice                              

Raziel  et.al,    2007(days  21,26)  

Four  8mes        

Barash  et  al,2003          

                                               (days  8,12,21,26)  

 

Endometrial  Injury  

• Cycle  preceeding  IVF  treatment  

• During  the  treatment  cycle  

• Follicular  phase  or  luteal  phase  

• Women  with  RIF  and/or  RPL    

• Women  undergoing  IVF  treatment  

• More  indica'on(s)……?  

Barash et al., 2003; Raziel et al.,2007; Zhou et al.,2006 Coughlan et al.,2013

Endometrial  Injury  

•  Endometrial injury on OPU day is

detrimental to IVF success rate Karimzade et al.,

2010

•  Endometrium requires at least 2 weeks to

achieve complete repair after mechanical

injury Li et al.,2011

•  Endometrial changes following injury are

sustained,and even increased in the

following cycle Kalma et al.,2009;Gnainsky et al.,2010

Endometrial  Injury  associated  with  :  

•  Local  inflammatory  response,cascading  a  release  of  pro-­‐inflammatory  cytokines  ang  growth  factors  like  IL-­‐  6,IL-­‐15,MIP-­‐1B,LIF,osteopon'n  and  TNF  alpha  which  induce  decidualisa'on  and  development  of  endometrium  favourable  to  implanta'on      

•  Gene  expression  in  the  endometrium,with  up  regula'on  of  pro-­‐implanta'on  proteins  such  as  mucin  1  transmembrane  (MUC1),cristallin  alpha  B,apolipoprotein  D  (APPOD),phospholipase  A2  (PLA2)    and  uroplakin  Ib  (UPIb)    

•  Increase  macrophages  and  dentri'c  cells  which  play  important  role  in  decidualisa'on  and  implanta'on  Kalma  et  al.,2009  ;  Gnainsky  et  al.,2010  

 Overall,with  local  injury  there  are  changes  ini'ated  within  the  endometrium                  the  immune  system  and  gene  expression,all  leading  to  improve  recep'vity  and  favourable  milieu  for  implanta'on.    It  could  be  that  injury  in  the  preceeding  cycle  is  more  effec've  as  all  these  events  require  'me  and  are  governed  by  the  hormones.Interven'on  closely  to  the  embryo  transfer  can  poten'ally  disturb  the  endometrium  and  may  have  nega've  effect  

Endometrial biopsy Endometrial Injury

macrophages/dendritic cells

•  tumor necrosis factor-a (TNF-a),

•  growth-regulated oncogene-a (GROa), •  interleukin-15 (IL-15),

•  macrophage inflammatory protein 1B (MIP-1B),

•  Osteopontin

A positive correlation was found between the levels of macrophages/dendritic cells, MIP-1B expression, and TNF-a expression & the pregnancy

outcome.

Gnainsky et al. Fertil & Steril 2010;94:2030

BACKWARD  DEVELOPMENT  HYPOTHESIS            

Endometrial  matura8on  is  abnormally  advanced  when  controlled  ovarian  s8mula8on  is  performed  during  ART    Lass  et  al.,1998;  Ubaldi  et  al.,1997    

 

COH  cycles  depicted  structural  and  func8onal  changes  when  compared  with  natural  cycles,  including  histological  advancement,  pinopodes  matura8on  advancement  and  steroid  receptor  downregula8on    Sebas8an  et    al.,  2004  

 

Endometrial  injury  performed  in  the  previous  cycle  might  retard  endometrial  matura8on  leading  to  beUer  synchronicity  between  the  

endometrium  and  the  transferred  embryo    Li  et  al.,  2009  

Results: Endometrial sampling of IVF patients using a biopsy catheter substantially increases their chances to conceive at the following IVF-embryo transfer cycle. By

transferring a similar number of embryos in the study and control groups, the authors achieved an implantation rate of 28 versus 14%, a clinical pregnancy rate of 67

versus 30% and a live birth rate per embryo transfer of 49 versus 23%.

Conclusion: These results suggest that IVF treatment that is preceded by

endometrial biopsy doubles the chance for a take-home baby.

Significant increase in clinical pregnancy and live birth rate

Fertil & Steril 2003;79:1317

2012  

Clinical pregnancy rate in the endometrial injury (hysteroscopy and

endometrial biopsy) and control groups.

Potdar,2012

Live birth rate in the endometrial injury (hysteroscopy and endometrial

biopsy) and control groups

Potdar,2012

Live birth rate in the randomized and non-randomized studies for

endometrial injury and control groups.

Potdar,2012

Peer  review  is  the  basis  for  the  crea'on  of  solid  and  trustable  knowledge  that  we  can  implement  in  the  treatment  of  our  pa'ents.  Now,  this  concept  is  being  tainted  and  diluted  by  a  

vicious  circle  created  by  the  use  of  inadequate  or  insufficient  data  to  compute  incorrect  or  incomplete  conclusions  that  are  touted  as  evidence-­‐based  medicine,  crea'ng  confusion  

instead  of  clarifica'on.  

Endometrial  straching  prior  star8ng  ART  treatment  

may  improve  the  chance  of  implanta8on  ?  

•  First  publica'on  made  by  Barash  et  al.,  in  2003  decade  later  this  interven'on  being  used  widely  by  some  colleaques  widely  advier'sed  on  their  the  web  sites  and  pa'ents  are  paying  to  undergo  ‘straching  cycle  ‘  before  their  ART  treatment  cycle  !  

•  Following  a  ‘trustworthy’  evidence-­‐based  medical  approach,these  colleaques  believe  that  there  giving  the  pa'ents  the  best  treatment  possible  because  new  treatment  op'on  based  on  more  thn  300  referances  (case  series,case  reports,case  controlled  studies,expert  opinions  etc.  ),  4  randomised  RCT  and  3  meta  –analyses    

•  RCT  published  in  journals  very  low  impact  factors  •  Meta-­‐analyses  some  very  important  methodological  problems(  different  

pa'ent  groups,different  defini'on  of  RIF,  some  pa'ents  have  no  implanta'on  failure,different  interven'on  procedures  and  techniques  etc.  )  

•   There  is  no  enough  data  and  it  is  not  sufficiently  conclusive  to  merrit  such  confidance  in  this  interven'on  !  

Endometrial straching prior starting ART treatment may improve the chance of implantation ?  

•  In the second systamatic review Potdar (2012),include the which have been already analysed,and hysteroscopy was included as another way of injuring endometrium. It should be kept in mind that hysteroscopic intervention may give additional benefit to the effect of the endometrial stracthing alone !

•  Combined effects of various procedures (using OC,GnRHa,GnRHant

•  Incorrect choosing of the studies to be included

•  If you put trush in, you get the trash out ????

Simon C and Bellver J, HR,2014

•  Is there evidence to demonstrate that ‘straching ‘ in the previous cycle modulates molecular/cellular phenotype induced by COS ?

WHAT DO YOU THINK ?

Conclusion  

There  is  an  urgent  need  for  large,mul8centre  randomised  studies  inves8ga8ng  local  endometrial  injury    and  pregnancy  outcomes  in  the  unexplained  RIF,in  pa8ents  unexplained  subfer8lity  undergoing  first  IVF  cycle  and  some  pathologies  with  dimineshed  endometrial  recep8vity  such  as  PCOS  and  endometriosis  

The  evidence  must  be  strengthened  by  simultenous  molecular  and  gene  expression  studies  on  endometrium  

Un8l  the  results  of  such  studies  available,or  an  expert  consor8um  quideline  proposed,it  should  be  a  blanket  policy  to  induce  local  endometrial  injury  for  women  undergoing  first  cycle  of  IVF  and  perhaps  there  is  a  role  for  this  in  women  with  unexplained  RIF  

Systema8c  and  standardized  hysteroscopic  endometrial  injury  

for  treatment  of  recurrent  implanta8on  failure  (RIF):  

Preliminary  results  of  prospec8ve  and  randomized  trial.      

Timur  Gürgan1,  Ziya  Kalem1,  Işın  Kocabaş1,  Müberra  Namlı  Kalem2,  Halil  Ruso1,  Antonis  Makrigiannakis3  

1:  Gürgan  Clinic  Women’s  Health  and  IVF  Centre,  Ankara,  Turkey.  2:Turgut  Özal  University  Hospital,  Department  Obstetrics  and  Gynecology,  Ankara,  Turkey.  

3:  University  of  Crete,  Department  of  Obstetrics  and  Gynecology,  Crete,  Greece  

 

Purpose:  To  inves'gate  the  effect  of  hysteroscopic  symmetrical  endometrial  injury  for  RIF  pa'ents.  

Method:  This  is  a  prospec've  and  randomized  controlled  trial  for  RIF  pa'ents  inves'ga'ng  the  effect  of  systemic  and  symmetric  endometrial  injury  using  office  

hysteroscopy.  Endometrial  injury  was  performed  on  the  follicular  phase  of  the  

menstrual  cycle  under  general  anesthesia.  The  main  variant  analyzed  was  the  clinical  pregnancy  rates.  Sta's'cal  calcula'ons  were  performed  on  GraphPad  Prism  version  

6.0  and  p<0.05  were  considered  sta's'cally  significant.  Findings:  Following  randomized  controlled  trial  we  propose  that  the  systemic  

endometrial  injury  model  can  be  standardized  to  increase  the  odds  of  implanta'on  in  

RIF  pa'ents  to  achieve  clinical  pregnancy.  

 

 

 

 

 

 

 

 

Our  Technique  :    

§  Symmetric,systema8c  Injury  on  the  fundus  

 a.  One  transverse  incision  

 b.  Symmetric  ver8cal  incisions  (6-­‐8)  around  line    

§  Hysteroscopy  

§  Follicular  phase  

§  Previous  cycle  before  ET  

§  RIF  

RIF(Recurrent  Implantation  Failure):    

Failure   to   achieve   a   clinical   pregnancy   aher   transfer   of   at  

least  4  good-­‐quality  embryos   in  a  minimum  of   three   fresh  

or  frozen  cycles  in  a  woman  under  the  age  of  40  years.    

VIDEO

Systema8c  and  standardized  hysteroscopic  endometrial  injury  

for  treatment  of  recurrent  implanta8on  failure  (RIF):  

Preliminary  results  of  prospec8ve  and  randomized  trial.      

Timur  Gürgan1,  Ziya  Kalem1,  Işın  Kocabaş1,  Müberra  Namlı  Kalem2,  Halil  Ruso1,  Antonis  Makrigiannakis3  

1:  Gürgan  Clinic  Women’s  Health  and  IVF  Centre,  Ankara,  Turkey.  2:Turgut  Özal  University  Hospital,  Department  Obstetrics  and  Gynecology,  Ankara,  Turkey.  

3:  University  of  Crete,  Department  of  Obstetrics  and  Gynecology,  Crete,  Greece  

 

Purpose:  To  inves'gate  the  effect  of  hysteroscopic  symmetrical  endometrial  injury  for  RIF  pa'ents.  

Method:  This  is  a  prospec've  and  randomized  controlled  trial  for  RIF  pa'ents  inves'ga'ng  the  effect  of  systemic  and  symmetric  endometrial  injury  using  office  

hysteroscopy.  Endometrial  injury  was  performed  on  the  follicular  phase  of  the  

menstrual  cycle  under  general  anesthesia.  The  main  variant  analyzed  was  the  clinical  pregnancy  rates.  Sta's'cal  calcula'ons  were  performed  on  GraphPad  Prism  version  

6.0  and  p<0.05  were  considered  sta's'cally  significant.  Findings:  Following  randomized  controlled  trial  we  propose  that  the  systemic  

endometrial  injury  model  can  be  standardized  to  increase  the  odds  of  implanta'on  in  

RIF  pa'ents  to  achieve  clinical  pregnancy.  

Systema8c  and  standardized  hysteroscopic  endometrial  injury  for  

treatment  of  recurrent  implanta8on  failure  (RIF):  Preliminary  results  of  

prospec8ve  and  randomized  trial.   Gurgan et al.

Control (n=40) Injury (n=44)

Average female age 30.76 33.48

Av. BMI 23.28 24.35 Av. No of previous cycles 3.57 3.57 Av. No of cumulative ET 6.29 6.26

Av. No of COCs 6.17 6.51

Av. No of MII eggs (%) 73.81 77.12

Av. Fertilisation rate (%) 96.53 89.24 Average ET day 3.14 3.09

Av. no of embryos transferred 1.9 2.02

Av. Endometrial thickness on

hCG day 10.33 9.46

Injury Performed NO YES

Av. cycle day of Injury - 10.86

Av. time from Injury to ET

(days) - 56.02

Clinical Pregnancy 17.50% 40.91% (p=0.02)

Implica8ons  for  Research  

Is endometrial injury effective in other ART situations ?

•  Cryopreserved embryos or gametes

•  Embryo or gamete donation

•  Uterine abnormalies

•  Endometriosis /endometriomas

•  Adenomyosis

•  PCOS

•  Any significant effect on

Miscarriage rate

Multiple pregnancy rate

KEEP ON WALKING !