{"paper_id":"6bbd2716-e23c-496d-8034-4455cfb7837f","body_text":"Recurrent implantation failure (RIF) is defined\nas the lack of any pregnancy in three consecutive\n in vitro  fertilization/ intracytoplasmic sperm injections-\nembryo transfer(IVF/ICSI-ET) cycles or\nten good-quality embryo transfers ( 1 - 3 ). Results\nof recent studies reveal that it is a financial and\nlegal obligation to restrict the number of embryos\ntransferred ( 4 - 6 ). Currently it is preferable to transfer\nonly one embryo or two embryos ( 4 - 6 ). In\nTurkey, in concordance with the guidelines of\nthe Ministry of Health General Directorate of\nMaternal and Infant Health and Family Planning,\nthe transfer of a single embryo at initial\ntwo attempts, excluding special circumstances,\nhas been legalized. Formerly, couples were diagnosed\nRIF if implantation failed after three\nconsecutive IVF/ICSI-ET cycles or after the\ntransfer of ten good quality embryos. However, single embryo transfers according to new legal\nmeasures make it a necessity to reconsider the definition\nof RIF.\nIn recent years, great advances have been\nachieved in the treatment of infertile couples.\nHowever despite these advances, there are still\nsome infertile couples who suffer from RIF.\nProbable underlying etiologies for RIF are aneuploidy\nof embryos, uterine cavity abnormalities,\ndiminished endometrial response, and insufficiencies\nin transfer techniques ( 2 ). These\nfactors result in decreased pregnancy rates even\nat successful IVF centers, and RIF remains a\nproblem, of both economical and psychological\naspects for couples.\nOur aim was to investigate the characteristics\nof our patients who suffer from RIF and to discuss\nthe management protocols in view of the\nliterature.\n\nIn this cross sectional study, patients who underwent\nIVF/ICSI cycles at İstanbul University\nCerrahpasa School of Medicine, Department\nof Obstetrics and Gynecology, IVF Unit from\nJanuary 2000-January 2007 were retrospectively\nreviewed to locate those patients diagnosed\nwith RIF. A total of 1822 cases out of 2183\nwere included in the study. Of these, 185 RIF\npatients were compared to 1637 patients who\ndid not have RIF. Patients with cycle cancellation\nand no oocyte during oocyte pick up or\nmen without sperm at TESE were all excluded\nfrom the study. The inclusion criteria was: age\nlimit of 42 years, basal follicle stimulation hormone\n(FSH) (day 3) level of <20 mIU/mL, and normal\ngynecological ultrasound and cervical smear.\nAll patients were given a written informed consent.\nThe local Institutional Ethics Committee\napproved the study.\nAll patients received the GnRH agonist leuprolide\nacetate (1 mg/day sc Lucrin®, Abbott-\nFrance Pharmaceuticals, France) beginning on\nthe 21 st  day the of previous cycle (long protocol)\nor the first day of the cycle (short protocol). Leuprolide\nacetate was reduced to 0.5 mg/day and\ngonadotropin 150-450 IU (Menogon®, Ferring,\nIstanbul; Gonal F®, Merck Serono, Istanbul; or\nPuregon®, Schering Plough, Istanbul, Turkey)\nwere initiated on the third day of menstruation\naccording to age, body mass index (BMI), basal\nFSH value, and prior ovulation induction trials.\nControlled ovarian hyperstimulation (COH) was\nmonitored by transvaginal sonography, and the\ngonadotropin dose was adjusted according to follicle\nsize and number. When three or more follicles\nreached >18 mm, we administered 10000 IU of\nhuman chorionic gonadotropin (hCG, Pregnyl®,\nSchering Plough, Istanbul, Turkey) for ovulation\ninduction.\nOocyte aspiration was performed transvaginally,\n35-36 hours after administration of the\nhCG injection. During the oocyte pick-up procedure,\nsedative anesthetics or local anesthesia\nwas used. Sequential medium was used for\nembryo culture and transfer. Embryos were selected\nfor transfer by pronuclei scoring, cleavage\nrate, fragmentation, and blastomere equivalence\nscoring. Assisted hatching was applied to\nembryos which had thick zona pellucida layers.\nQuality of embryos and age of the patients were\nthe main factors in determining the number of\nembryos to be transferred. Hard manipulations,\nbleeding from cervix during the transfer procedure,\nor the use of a tenaculum were considered\n\"difficult transfer\".\nThe luteal phase was supported by progesterone\n(200 mg, Progynex®, Koçak, Istanbul,\nor Crinone gel® 8%, Merck Serono, Istanbul)\nadministered vaginally three times daily or 100\nmg progesterone IM injections daily (Progynex\n® ampule, Koçak, Istanbul). In appropriate\ncases, embryos were followed until the blastocyst\nphase and transfer was performed at that\ntime. Clinical pregnancy was defined as the detection\nof a gestational sac on the ultrasound.\nImplantation rate was defined as the number of\ngestational sacs over the number of embryos\ntransferred. Pregnancy rate was defined as the\nnumber of pregnancies with visible fetal heart\nactivity on ultrasound examination over the\nnumber of transferred embryos.\nResults were expressed as mean ± SD, frequency,\nand percentages. Analyses were performed\nby Unistat 5.1 software. Categorical characteristics of patients were compared with\nthe chi square test. Independent Samples t-test\nand Mann Whitney U tests were used for comparison\nof numeric variables. P<0.05 was considered\nstatistically significant.\n\nIn our study, 589 couples achieved pregnancy\nout of 1822 (32%). Implantation rates were\nas follows: 10% (first attempt; n=1424); 9.6%\n(second attempt; n=435); 11% (third attempt;\nn=201); 5.8% (fourth attempt; n=91); 2% (fifth\nattempt; n=41), and 6% for >5 attempts (n=75).\nSuccess rates diminished significantly after the\nthird attempt.\nAccording to age, implantation and pregnancy\nrates were 10% and 29.5% under 35 years; implantation\nrate was 7% and pregnancy rate was\n25.7% between 35-39 years while implantation\nrate was 2% and pregnancy rate was 12.8%\nover 40 years.\nSubjects had the following diagnoses: tuboperitoneal\nfactor (314), male factor (1320),\npolycystic ovary syndrome (PCOS, 115), unexplained\ninfertility (50), hypogonadotropic\nhypogonadism ( 14 ), uterine factor ( 4 ), and 5 had\nendometriosis ( Table 1 ).\nEtiology of the infertile patients\nThe group characteristics and results have\nbeen given in table 2. Non-RIF patients constitute\ngroup I, which included 1637 cases. Group\nII comprised 185 cases of RIF. The mean age\nwas 32.48 ± 5.24 years in group I and 35.93 ±\n4.76 years in group II (p<0.0001). Mean duration\nof infertility was 8.25 ± 5.05 years in group\nI and 11.04 ± 5.30 years in group II (p<0.0001).\nThe mean weight of subjects in group I was\n65.92 ± 10.85 kg and 69.85 ± 11.52 kg in group\nII (p<0.003). Mean values for waist circumferences\nwere 82.88 ± 10.89 cm in group I and\n88.12 ± 12.89 cm in group II (p<0.016).\nGroup’s characteristics and treatment features\nns; Not significant.\nDay 3 FSH values were 7.45 ± 3.86 IU/ml\nin group I and 8.95 ± 6.55 IU/ml in group II\n(p<0.0001). The total number of 75 IU gonadotropin\nampules administered was 29.85 ± 13.93 in\ngroup I and 37.93 ± 15.30 in group II (p<0.0001).\nTotal gonadotropin dose was 2392.45 ± 1209.49\nIU in group I and 2989 ± 1262.37 IU in group II\n(p<0.0001).\nEstradiol (E2) values on hCG day were 2001.95\n± 1617.75 pg/ml in the first group and 1621.47 ±\n1184.36 pg/ml in the second group (p<0.003). The\nmean value of serum progesterone level on the\nhCG day was 0.96 ± 0.63 ng/ml in group I and\n3.37 ± 1.48 ng/ml in group II (p<0.001).\nThe mean number of MII oocytes were 4.1 ± 3.5\nin group I and 3.9 ± 3.9 in group II; there was no\nstatistical significance between groups. The mean\nendometrial thicknesses were 10.27 ± 2.45 mm in\ngroup I and 11.33 ± 1.28 mm in group II, which\nwas not statistically significant.\nThe mean number of fertilized oocytes were 4.78\n± 3.05 in the non-RIF group and 4.13 ± 2.95 in the\nRIF group (p<0.006). The number of transferred\nembryos was 3.49 ± 1.4 in the non-RIF and 3.27 ±\n1.65 in the RIF group (p<0.045).\nBlastocyst transfers were done in 18 patients\nin group I and 7 patients in group II. The mean\nnumber of transferred blastocysts were 2 ± 1.32 in\ngroup I and 3.14 ± 0.69 in group II (p<0.043). Assisted\nhatching was applied to 19 patients in group\nI and 8 patients in group II.\nAccording to Kruger’s criteria, the sperm parameter\nmorphology was 3.81 ± 2.27 % (group II)\nvs. 3 ± 2.19 % (group I) and motility was 72.32\n± 20.15% (group II) vs. 66 ± 23.36% (group I)\n(p<0.001).The values were found to be significantly\nbetter in the RİF group.\nThe groups were also compared for singleton\nand multiple pregnancies. In the first group,\nrates for singleton pregnancies were 13.5%,\ntwin were 5.4%, and triple were 1.9%, while\nthey were 8.5% (single), 3.5% (twin), and 0.5%\n(triple) in the second group. Multiple pregnancy\nrates were lower in the RIF group compared to\nthe non-RIF group.\nEmbryo transfer was classified into easy and difficult\ntransfers. In group I the transfer was easy in\n91.6% of cases, and in group II it was easy in\n92.9% of cases. The transfer technique was not\nsignificant between the groups. Ultrasonography\nwas used in 52.3% of the transfers in group I and\n44% of the transfers in group II; there was no\nsignificant difference.\nGroup’s pregnancy rates\n\nRecurrent IVF failure continues to be an important\nproblem and a distressing condition for couples.\nDespite recent advances in medical technology, implantation\nrates still remain low. Our implantation\nrate was reported as 10% for the first attempt and\ndiminished significantly after the third attempt. As\nnoted in the literature, implantation and pregnancy\nrates decrease after the fourth attempt ( 7 ).\nIn our study, we found that the RIF group consisted\nof women with poor prognoses. In contrast,\nsperm morphology and motility were better in that\ngroup. Severe male factor was treated successfully\nin the first attempts, as they were probably married\nto normal fertile women.\nWomen in the RIF group had advanced mean\nage, higher day 3 FSH levels, longer infertility\ndurations, and a higher mean weight when\ncompared to non-RIF women. These differences\nwere all statistically significant and can be defined\nas poor prognoses factors for women who\nunderwent IVF.\nIt has long been known that with increasing age\nthere is a decline in natural fecundity and pregnanacy\nrates. Along with the decrease in follicle\nnumber, the oocyte quality also diminishes ( 8 ).\nIn recent decades, numerous reports regarding\nthe outcome of ART treatment have confirmed that\nthe probability of a live birth decreases distinctly after the age of 35 years ( 9 ).\nWalsh et al. stated that couples with RIF had\npoor prognosis and the pregnancy rates decreased\nfurther over the age of 35 ( 10 ).\nIn our study the mean age of the RIF group was\n35.93 years, which was older than the non-RIF\ngroup. Maheshwari et al. have concluded that\nolder women were more likely to have a diagnosis\nof unexplained infertility compared with\nthose who were younger. They also reported that\nthe duration of infertility was more widespread\nin older women, which was compatible with our\nfindings ( 11 ).\nBoth increasing age and basal FSH were significantly\nassociated with reduced numbers of oocytes\ncollected, oocytes fertilized, and embryos\ntransferred. Markers of ovarian reserve, day 3\nFSH, inhibin B and E2, anti-müllerian hormon\n(AMH), antral follicle count (AFC) are particularly\npredictive and useful in guiding the choice\nof the optimal protocol for ART. However, no\ntests have been absolutely predictive of a successful\noutcome. Today there is no technology\nthat can predict the IVF outcome or estimate the\nRIF group ( 12 ).\nIn our study we found a statistically significant\ndifference for weight between the two groups in\nfavor of the non-RIF group. The published data\nregarding the effect of body mass index (BMI)\non IVF cycles is varied. Some studies highlighted\na state of gonadotropin resistance in obese\nwomen, which lead to higher gonadotropin requirement\nfor COH ( 13 ). Many studies indicated\nlower implantation and pregnancy rates and\nhigher miscarriage rates ( 14 ). Nichols et al. and\nWang et al. both have reported reduced conception\nrates in overweight women undergoing IVF\n( 15 ,  16 ). Other studies did not show any adverse\neffects of obesity on endometrial thickness, hormone\nlevels, oocyte number and quality, implantation,\nand pregnancy rates ( 17 ,  18 ).\nIn our study the numbers of metaphase II\noocytes obtained were similar in both groups, but\nin the RIF group we used a higher amount of gonadotropin\nand a lower mean level of E2 on hCG\nday was calculated.\nKably Ambe et al. have shown that E2 levels\non hCG day is not an influential factor on pregnancy\nrates, especially in older patients ( 19 ). In\ncontrast, Orvieto et al. have evaluated the influence\nof the ratios of E2 to the number of follicles\n>14 mm on the day of hCG administration\n(E2/follicle) by comparing the two different\nprotocols. They reported that within the antagonist\ngroup higher pregnancy rates were observed\nwhen comparing those with an E2/oocyte ratio\nof 100-200 pg/ml to others who had an E2/oocyte\nratio <100 pg/ml or >200 pg/ml ( 20 ).\nIn our study the serum progesterone level on\nthe hCG day was higher in the RIF group due\nto early luteinization. Early luteinization incidence\nvaries, ranging between 5% and 30% in\nIVF patients. It may adversely affect the clinical\noutcome and could be related to diminished\novarian reserve. It is not necessarily a LH-de\npendent event and is observed mostly in women\nof advanced age ( 21 ).\nConcurrent to our study, Ozturk Turhan et\nal. have reported that in the group whose progesterone\nlevels were higher than 1.5 ng/ml\non the hCG day, mature oocytes, fertilization,\nand cleavage rates were significantly lower\n(p<0.05) ( 22 ).\nEarly luteinization leads to more post-mature\noocytes at oocyte pick-up and higher progesterone\nlevels disturb endometrial maturation and\nintegrity. Furthermore, fewer oocytes are fertilized\nand go under cleavage. As a result, the\nprogesterone level has been shown to be higher\nin the RIF group and the mean number of transferred\noocytes was lower compared to the non-\nRIF group.\nSperm count and motility were better in the\nRIF group, which lead us to conclude that our\nRIF patients constituted abundant, poor responder\nwomen and accordingly we needed to\nobtain better quality oocytes and prevent premature\nluteinization.\nWe measured endometrial thickness on\nthe hCG day and did not find any difference.\nRichter et al. stated that thicker endometrium\nincreased clinical pregnancy, continuing pregnancy\nand live birth rates independent from\nage and embryo quality ( 23 ). In another study, pregnancy rates dropped at endometrial thicknesses\nunder 7 mm, but the authors recommended\nembryo transfer because pregnancies\nwere obtained ( 24 ).\nIn our study, more embryos were transferred\nin patients without RIF. They also had a greater\nnumber of embryos available for transfer,\nwhich was statistically significant (p<0.024). In\nIVF procedures, the embryo number to be transferred\nis increased when the patient has adverse\nprognostic factors such as higher age, poor\nembryo quality, and RIF. Fewer embryos are\ntransferred in couples with secondary infertility\nthat already have healthy children. Although it\nis the usual practice to transfer three embryos\nin Turkey, in couples who obviously have a\nbetter prognosis single embryo transfer is the\ntreatment of choice. Frequently up to three embryos\ncould be transferred in the presence of\nadvanced maternal age and/or poor embryo\nquality. However, even in the presence of an\nobviously positive prognosis, more than half of\nthe physicians prefer to transfer three embryos,\nand the percentage of doctors choosing single\nembryo transfer has remained below 15% ( 25 ).\nThe guidelines published in 2006 emphasized\nthat embryo transfers yielded more successful\noutcomes if they were performed at the blastocyst\nstage in IVF cycles in order to reduce and prevent\nmultiple pregnancies. It has been determined essential\nto transfer one or two embryos for those\nunder 35 years old, a maximum of three embryos\nfor those between 35-37, three embryos between\n38-39, and four embryos for those over 39 years\nof age ( 26 ). In Turkey, the most recent regulations\nthat came into effect in 2010 stipulated application\nof single embryo transfer in infertile women under\nthe age of 35 in the first two attempts ( 27 ). This\nimplicated the need for a new definition of RIF.\nIn order to increase implantation rate, more\nblastocysts were formed and transferred in the\nRIF group. Transferring the embryos in blastocyst\nstage resulted in higher implantation and\nlive birth rates in the RIF group ( 28 ,  29 ). Margalioth\net al. demonstrated that blastocyst transfer\nincreased implantation rates in patients with\nRIF ( 2 ). In our clinical practice we also prefer\nto transfer more blastocyst stage embryos in\nRIF patients.\nThe practice of assisted hatching was more frequent\nin the non-RIF group. Sallam et al. concluded\nthat assisted hatching increased the rates of ongoing\npregnancy, implantation and pregnany ( 30 ).\nCochrane data indicated that assisted hatching increased\nclinical pregnancy rates, but there was insufficient\nevidence about the effect on live birth\nrates ( 31 ). Currently there is inadequate evidence to\nrecommend routine assisted hatching.\nAs recommended in the literature, in our unit\nblastocyst transfer is preferred in appropriate patients,\nassisted hatching is used for thick zona pellucidas,\nembryo quality is evaluated by embryo\nscoring systems, and embryos of the highest quality\nare transferred, in order to have a better implantation\nand pregnancy rate.\nIn the literature, ulitrasound-guided embryo\ntransfer was associated with increased rates of\nclinical, ongoing, and live pregnancy rates compared\nwith the transfers made without ultrasonography\nguidance ( 32 ). In our study, the groups had\nno difference in terms of transfer technique and\ntransfer difficulty.\n\nIn our study we found that the group with RIF\nwas composed of poor prognosis patients who\nwere older, overweight, had a longer infertility duration,\nan elevated FSH level, and needed to use\nmore gonadotropins in COH.\nSperm motility and morphology were better in\nthe RIF group compared to the non-RIF group and\nmultiple pregnancy rates were lower in RIF patients.\nIn such patients, the RIF probability must\nbe taken into account and an appropriate treatment\nmust be made individually.","source_license":"CC-BY-4.0","license_restricted":false}