1. Justification and benefit of
adjuvant therapy in IVF/ICSI
Prof. dr. sc. Miro Kasum
Klinika za ženske bolesti i
porode
Petrova 13, Zagreb

2. Factors
 Fetal
– Assisted hatching
– Preimplantation genetic
screening
 Other methods
– Acupuncture
– Endometrial biopsy
 Maternal
– Aspirin
– Glucocorticoids
– Growth hormone
– Dehydroepiandrosterone
– Sildenafil
– Heparin
– Immnoglobulin
– Antibiotics

3. Assisted hatching (AH)
 Before an embryo implants
into the uterus it must hatch
from the zona pellucida
 Definition:
Artificial disruption
(thinning) or making a small
hole in the zona pellucida
– Easier for hatching to
occur
 Methods
– Chemical
– Mechanical
– Laser

4. Indications and success rates
 Older women
 > 37years
 Poor embryo quality
 Thick zona pellucida
 Repeated failed IVF cycles
– 3 or more ET without
pregnancy
 > FSH levels
 No evidence to recommend
or determine any effect of
AH on LBR
 Seif MM, Cochrane
Database Syst Rev 2006
 Improvement in CPR with
AH means that a clinic with
a success rate of 25% could
anticipate improving the
CPR to between 29% and
49%
– Das S, Cochrane
Database Syst Rev 2009

5. Preimplantation genetic screening
(PGS)
 3 days after the embryos are
created in the laboratory
 Removal 1 or 2 cells
 The genetic material (mainly
chromosomes)
 Testing for abnormalities
(aneuploidy screening)
 Embryos having both a normal
test result and physical
appearance should be
transferred
 Physical appearance means
embryos should have at least 5
cells on day 3

6. Indications and effectiveness
 A family history of
genetic disorders
 Repeated unexplained
miscarriages
 Advanced maternal age
– > 35 years
 No evidence of a beneficial
effect of PGS as currently
applied on the LBR after IVF,
but, for women of advanced
maternal age PGS significantly
lowers the LBR
 Technical drawbacks and
chromosomal mosaicism
underlie this inefficacy of PGS
 New approaches in the
application of PGS should be
evaluated carefully before their
introduction into clinical practice
 Mastenbroek
S, HRU, 2011

7. Maternal factors and other methods
 Aspirin
 Glucocorticoids
 Growth hormone(GH)
 Dehydroepiadrosterone
(DHEAS)
 Sildenafil
 Heparin
 Intravenous immunoglobulin
(IVIg)
 Antibiotics
 Acupuncture
 Endometrial biopsy

8. Aspirin
 Properties:
– Arachidonic acid
– < Cyclooxigenase
– < Prostacyclin (PGI2)
– << Thromboxane A2
(TXA2)
 Effects:
– Vasodilatatory
– Anti-inflammatory
– Platelet aggregation
inhibition

9. Aspirin following ET
 Aspirin 75 mg
– Alternate days from
the day of ETuntil 18
days after retrieval
 Evaluation:
– Ovarian blood flow
– Folliculogenesis
– Ovarian
responsiveness
– Uterine vascularity
and receptiveness
 RCT of 1380 women
– LBR
27% (with aspirin)
23% (without aspirin)
– Waldenstroem U, FS
2004
 Low-dose aspirin does not
improve IVF outcome and it
cannot be recommended for
routine clinical use
– Revelli A, FS 2008; Duvan CL,
JARG 2006; Fratarelli JL, FS
2008; Gelbaya TA, HRU 2007

10. Glucocorticoids
 Immunomodulators
– > Intra uterine environment
– > Implantation rate
– < NK cells
– < Cytokines
– < Endometrial inflammation
– Boomsma CM,
Cochrane Database
Syst Rev 2007
– Tetsuka M, JCEM
1997
– Miell JP, JE 1993
 > Ovarian response to
gonadotrophins
 Dexametasone
– => enzyme 11-beta
hydroxysteroid
dehxdrogenase type 1
– => Directly influence
follicular development
– => Indirectly by increasing
serum GH, IGF-1, and
consequently follicular fluid
IGF-1 levels

11. Glucocorticoids and success rates
 1 mg dexamethone
 10 mg prednisolone
 > Implantation rate
– 16.3 vs. 11.6% (NS)
 > Pregnancy rate
– 26.9 vs. 17.2% (NS)
 < Cancellation rate
– 2,8 vs. 12,4% (SS)
– Keay SD, HR 2001
 > Pregnancy rate
– Borderline (SS)
– Boomsma CM,
Cochrane Database Syst
Rev 2007

12. Growth hormone (GH)
 > Intraovarian IGF-I
 Addition of IGF-I to gonadotrophins
– Demonstration in animal and human studies
 > Gonadotrophin action in granulosa cells in poor responders
– Augmentation of the activity of aromatase
– Increase of E2-17 beta, P4, LH-r
– Augmentation of follicular development
– Increase of oocyte maturation
 Hypothesis for the introduction of GH to enhance ovarian
steroidogenesis and follicular develpoment and the ovarian
response acting sinergistically with FSH
– Yoshimura Y, BR 1996, Suikarri AM, FS 1996

13. GH during ovulation induction
 Mostly studied poor responders
 4 -12 IU of GH
– sc
 Starting on the day of ovarian
stimulation with gonadotrophins
 > Retrieved oocytes
– 7.5 vs. 3.5 (p< 0.001)
 > PR
– 60%
 Ibrahim ZH, FS 1991
 No significant differences
– Number of follicles and
oocytes, gonadotrophin dose,
cancellation, PR
 No support for the use of GH as
adjuvant th
 Suikkari AM, FS 1996, Shaker
A, FS 1992, Kotarba D,
Cochrane Library , 2002

14. Dehydroepiandrosterone (DHEAS)
 Primarily adrenocortical reticularis zone origin
 In high amounts during reproductive life
 Progressive decline with age
 Speculation that HRT in the elderly may have age-retardant
effects
 Essential sustrate for steroidogenesis
– < DHEAS => < testosterone, < E2-17 beta
– > DHEAS (oral supplementation) => > IGF-I
 Orentreich N, JCEM 1984, McNatty KP, S 1979, Casson PR,
HR, 2000

15. DHEAS before ovulation induction
 Mostly studied
– Women with diminished
ovarian reserve
– Repeated IVF failures
 Oral supplementation
 75 mg daily
 2 – 4 months before
ovulation induction with
gonadotrophins
 > E2-17 beta
 Casson PR, HR 2000
 > IGF-I
 Casson PR, E, 1998
 > Outcome in CC resistency
 Trott E, FS, 1996
 > CPR
 < Dose of gonadotrophins
– Particularly 35-40 years
 Barad D, HR 2006
 May augment ovulation
induction
 Beneficially affect oocyte
and embryo quality and PR

16. Sildenafil
 A potent cGMP-specific
phosphobodies-terase 5
inhibitor
– Its selective inhibition of
cGMP catabolism in
cavernous smooth muscle
tissue augments penile
erection
 Fagelman E, U, 2001
– Vaginal sildenefil improves
uterine artey blood flow
and sonographic
endometrial appearence
 Sher G, HR 2000

17. Sildenafil during ovarian stimulation
 7 days of sildeneafil
– > Uterine artery blood flow
 The combination of sildenafil
and estradiol valarate
– >Uterine artery blood flow
– > Endometrial thickeness
 Sher G, HR 2000
 Vaginal route for 3 to 10 days
– > 2 previous > IVF failures
 > PR (SS)
– < Endometrial thickness
 > 9 mm
– Sher G, FS 2002
 Promising studies *
 The addition of silldenefil to
an estrogen supplemented
regimen
 Previously failed to achieve
an endometrial thickness
greater than 8 mm
– No increase in endometrial
thickness
– No increase in blood flow
 Check JH, HR 2000
 Sildenefil has not
demostrated a definitive role

18. Heparin
 Treatment of choice
– Recurrent pregnancy loss due to aPL antibodies
 Heparins are involved in activities anticoagulation
and adhesion of the blastocyst to the endometrial
epithelium and subsequent invasion
 aPL may be responsible
– < Phospholipid adhesion molecules of trophoblast
– < hCG release
– < Trophoblast invasiveness
– < Trophoblast differentiation in vitro
 Fiedler K, EJMR 2004, Di Sormone N, AR 2000

19. Heparin and success rates
 Assumption
– < Immunological status
– < Embryo implantation
 Seropositive women in IVF
– at least one aPL
 Heparin 5000 IU, Aspirin
100 mg daily
 NO significant difference in
PR those treated and those
receiving placebo
– Quenby S, FS
2005, Stern C, FS
2003
 Seropositive women
– > 3 IVF failures
– at least 1 thrombophilic
defect
 Enoxaparin (Low
molecular weight heparin),
40 mg daily
 > CR,> PR, > LBR/ placebo
 20,9% vs. 6,1%
 31% vs. 9,6%
 23,8% vs. 2,8%
 Qublasn H, HF
2008

20. Immunoglobulin (IgG)
 Indications
– > Embryo failure
– > Recurrent miscarriage
> Inappropriate
immune response
> Proinflammatory
cytokines
 Preparations of IgG contain
– All humoral IgG
antibodies
– Normally in the plasma
of blood donors
 Effects of IgG:
– < Proinflammatory citokynes
– > Antinflammatory cytokines
– < NK cells
– < Pathological antibodies
 Dose:
– 500 mg iv / kg before ET
 Carp HJ, CRAI 2005
 Coulam CB, EP 2000

21. IgG before ET
 No improve in PR
 Stephenson MD, FS
2000
 No benefit
 Balasch J, FS 1996
 > LBR (SS), meta
analysis, 3 RCT
 Clark DA, JARG 2006
 > PR (56% vs. 9%)
 Coulam CB, EP 2000
 > Outcomes in specific
group of IVF patients
with positive APA
 Sher G, AJRI 1996

22. Antibiotics
 Vaginal antisepsis, negative effect
– < Quality of the oocytes and the embryos
 Bacterial vaginosis, negative effect
– < H2O2 producing lactobacilli
– < CR
– > EPL
 Bacterial contamination of the ET catheter tip
 Significant negative effect
– < CR
– < ZP
– > Endometritis
 > Cytokines, > Macrophages, > Prostaglandins, > Leukocytes
 Salim R,HR 2002; Spandorfer S, JRM 2001; Moore DE, FS 2001

23. Controversial role of antibiotics
 Ceftriaxone +
metronidazole
 At oocyte recovery
– Reduction of bacteria on
the transfer catheter clip
(78,4%)
– > CR
 21,6 % vs. 9,3%
– > CPR
 41,3% vs. 18,7%
– Egbase PE, Lancet 1999
 Amoxycillin + clavulanic
acid 1g/1,25, RCT
 At oocyte recovery + 6 days
 > Pregnancy loss rate
– 33,3% vs. 20,8% (p=9,15)
 Not recommend this
antibiotic prescription *
 Ensure maximum catheter
sterility *
 Peikrishvili R, JGOBR
2004

24. Acupuncture
 Used in China for centuries
to regulate the female
reproductive system
 Recent popularity in the
western world
 3 potential mechanisms
– > Neurotransmiters, GnRH,
FSH, E2, “O”
– > Uterine blood flow
– < Endogenous opioids
 Cho ZS, PNAC 1998

25. Beneficial effects of acupuncture
 Timing of administration:
– During ovarian stimulation
– At oocyte recovery
– At ET and afterward
 A number of systemic
reviews and meta-analysis
have been conducted on its
efectiveness as an adjuvant
treatment
 > CPR, > LBR
 Manheimer E, BMJ 2008
 > PR
– Ng EH, BJOG 2008
 > CPR, > LBR
 El-Toukhy T, BJOG 2008
 > LBR
 Placebo effect and small
sample size cannot be excluded
*
 Not recommended as a routine
use procedure *
 Cheong YC, Cochrane
database Syst Rev 2008

26. Endometrial biopsy (Pipelle)
 EB vs. Local injury
 > Wound-healing effect
 > Decidualization
 > Cytokines
 > Growth factors
 > Uterine receptivity
 > Implantation
 > PR
– Animal studies
 Indications
 < Endometrial receptivity
 > Intrauterine adhesions
 > Endometrial iregularity (US)
 < Endometrial thickness (US)
– Raziel A, FS 2007;
Basak S, AJRI 2002

27. Benefits of scratching (EB)
 On days 10-13 and 20-24 of
previous cycle
 > genes encoding membrane
proteins important during
implantation
– Kalma Y, FS 2009
 > CR
– 27,7% vs. 14,2%
 > CPR
– 66,7% vs.30.3%
 > LBR
– 48,9% vs.22.5%
– Barash A, FS 2003
 > CR following excision of polyp or
thickened endometrium
– Li R, FS 2008
 > CR, > CPR, > LBR
– Zhou L FS 2008
 Results are promising
 Prospective controlled
studies are still needed to
confirme the procedure
 Validitation in a large
randomized study may lead
to the routine performance
of EB in conjuction with IVF

28. Conclusions
 The expense, time, stres and
frustration felt by physicians and
15% of couples with difficulties in
conceiving are searcing for new
drugs and tecnologies that will
increase succes rates
 However, progress has been
limited because none of the
available adjuvant treatments has
a clear advantage
 If the embryos are genetically
abnormal, no maternal adjuvant
therapy will improve the pregnancy
rate
 Some of the therapies may prove
efficacious in subgroups of
patients
 Treatment often needs to be
“tailor-made” to suit the individual
patient
 Low molecular weight heparine
may be effective against
antiphospholipid antibodies,
other than LE and ACA
 EB may benefit patients with thin
and nonresponsive endometrium
 Ig may benefit patients with high
NK cell numbers, or enhanced
killing activity