2. • Implantation is a process of attachment of the embryo to the luminal
epithelium, migration via the luminal epithelium and invasion into
deep layer of the endometrium to become embedded in the deep
layer.
• Implantation is successful – visualization of the gestational sac
3. Recurrent Implantation Failure
• Absence of implantation after three or more transfers of high quality
embryos
• Absence of implantation after transfer of > 10 high quality embryos in
multiple cycles
• Failure to achieve clinical pregnancy after transfer of at least 4 good
quality embryos in a minimum of three fresh or frozen cycles in a women
< 40 y
• C Coughlan., Recurrent implantation failure definition and management.
Reproductive bio medicine online 2013
7. Recurrent Implantation Failure
• Age
• Maternal age is single important variable predicting successful
implantation
• Reduced ovarian reserve, poor response to ovarian stimulation, high
aneuploidy
8. Recurrent Implantation Failure
• Parental Genetics
• Translocation – Reciprocal ( exchange between 2 non homologus
chromosomes)and Robertsonian ( fusion of 2 acrocentric
chromosome resulting in formation of chromosome with 2 large arms
and loss of short arms)
• 2.5 % of the couple with RIF
• 4.7 % of RPL
• ? Should be performed in pts with RIF
• Abnormal Parental karyotype should be counselled for PGD
9. Recurrent Implantation Failure
• Quality of embryo
• Cleavage stage embryo (4-8 cell stage)- controlled by maternal RNA
transcripts
• Embryonic genome begins on the day 3 and cont till blastocyst stage
• Blastocyst has a higher implantation potential
10. Recurrent Implantation Failure
• Sequential culture media
• First culture- pronucleus to compaction
• Non essential amino acids, Ethylene Diamine Tetraacetic Acid,
pyruvate, reduced glucose
• Second culture- compaction to blastocyst
• Essential amio acids, removes EDTA, reduced pyruvate and increased
glucose for meeting the energy demands
• Global culture media is available
• Sequential culture media helps in selection of most suitable embryo
for transfer.
11. Recurrent Implantation Failure
• Ovarian response and implantation
• High ovarian responders- create excess embryo, selection of best one
for blastocyst culture
• The application of blastocyst transfer will permit the observation of
embryonic growth well to its advanced stages and enable better
embryo selection
• Poor responders- less embryo, may arrest at the cleavage stage
embryo
• Prolonged culture of small no of embryo –no significant advantage
• High responders may be benefitted with prolonged culture condition
12. Recurrent Implantation Failure
• Embryo genetics
• FISH used to diagnose aneuploidy of X,Y, 18,13 & 21
• Comparative Genomic hybridization for 24 chromosomes showed,
aneuploidy of 58% at the age of 40 and 100 % at the age of 47.
• Fertility sterility 2014
13. Recurrent Implantation Failure
• Embryo genetics- role of biopsy
• Biopsy of cleavage stage embryo abandoned
• Due to high rate of mosaicism at day 3 followed by self correction
• Comparative genomic hybridization
• Pre Implantation Genetic Diagnosis by trophoectoderm biopsy
• CGH is a molecular technique – entire genome to be scanned for DNA
copy number
• Total genomic DNA is isolated and compared with reference cell
• Can cryopreserve the blastocyst and transfer in next cycle
14. Recurrent Implantation Failure
• Out come of various studies – using PGS for RIF
• Reduced live birth rates
• Increased rate of aneuploidy
15. Recurrent Implantation Failure
• PGS in RIF
• Trophectoderm biopsy (greater resiliency, less mosaicism and ability
to analyze multiple cells)
• Beneficial for women > 40 y with RIF
• Improved live birth rate for PGS and frozen transfer
• PGS in young RIF is less established how ever can be considered till
further studies
• Biopsy and analysis does not increase the implantation potential of
any euploid embryo
• Adds cost, invasiveness, potential of discarding the normal embryo
16. Recurrent Implantation Failure
• Sperm genetics
• Sperm DNA integrity with semen analysis
• Sperm DNA damage ~ poor reproductive outcome
• Increased DNA fragmentation ~ RPL
• Sperm DNA damage is lower in seminiferous tubules than in
epidydimal or ejaculated sperms
• RIF with high DNA fragmentation- testicular sperm retrival
• Intracytoplasmic Morphologically Selected Sperms
• Spermatozoa with large vacuoles in HPM have increased DNA defects
17. Recurrent Implantation Failure
• Sperm DNA fragmentation tests
• Sperm Chromatin structure assay
• Terminal Deoxynucleotidyl transferase mediated dUTP nick end
labeling (TUNEL)
• Sperm Chromatin dispersion assay
• None are able to identify the clinically important DNA damage
18. Recurrent Implantation Failure
• Uterine pathology- 25 to 50%
• Fibroids, polyps, intra uterine adhesions, chronic endometritis, Mullerian
anomalies
• Removal of sub mucous and intramural myoma
• Hysteroscopy
• Incidence of chronic endometritis is 30%
• Antibiotic treatment of Chronic endometritis
• Adenomyosis- disrupting the endo myometrial junction (> intramural
myoma)
• 3D usg, hysteroscopy
19. Recurrent Implantation Failure
• Endometrial inflammatory markers
• Restin, leptin, IL 22, aberrant synthesis of endometrial prostaglandin
synthesis
• Dysregulation of 313 genes and 63 transcripts
• Molecular diagnosis of receptive endometrium
• Endometrial receptivity array
21. Recurrent Implantation Failure
• Technique
• Hardening of the zona
• Cleaved embryo with thin zona implant better
• Mechanical or chemical, laser assisted hatching
• Laser assisted thinning of the Zona without complete breach, limiting
for the quarter of the circumference
• Culture of the oocyte with the cumulous oophorus
22. Recurrent Implantation Failure
• Endometrial scratch…..no proven benefit
• Co culture with tubal epithelium, endometrial epithelium, cumulus
cells
• Xeno culture- risk of infection
• Human tubal cells harvested during hysterectomy/ tubal ligation
• Risk of Creutz-feldt Jacob disease
• Patients own endometrial cells- beneficial
• Mid to late luteal phase endometrium
26. Recurrent Implantation Failure
• Investigations
• FSH, AMH, AFC
• ? Sperm DNA testing…
• Karyotyping of the couple
• TVS
• Hysteroscopy
• Detailed counselling
27. Recurrent Implantation Failure
• Management
• Life style changes
• BMI
• Review of stimulation protocols
• Medical treatment to improve sperm quality
• Testicular sperm retrieval + IMSI
• Blastocyst transfer
• Assisted Hatching (risk of MCDA)
28. Recurrent Implantation Failure
• Metabolomics- studying the functional capacity of the embryo before
transfer
• Embryo transfer technique
• Improvement of the endometrial lining with estrogen
• Use of sildenafil to improve endometrium
• GSF flushing of the endometrium
