Its definition is dynamic and depends on the population
of patients studied, as well as the type and quality of clinical
practice. Mitri et al; 2016
no universally accepted definition for RIF, despite many
publications on this topic (Das and Holzer, 2012; Laufer and Simon,
2012; Penzias, 2012; Simon and Laufer, 2012a,b; Urman et al., 2005).
Implantation failure after transfer of three high-quality
embryo or with transfer of ≥10 embryos in multiple
transfers with exact numbers to be determined by each
[Thornhill AR, ESHRE PGD Consortium, et al. Best practice guidelines for clinical
preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS). Hum
Should be revised after the era of SET/DET
Recurrent implantation failure
Recurrent IVF failure
RIF is not the same as recurrent IVF failure.
Recurrent IVF failure is the failure to achieve a pregnancy
after several IVF attempts, a common cause being poor
response to ovarian stimulation (Ferraretti et al., 2011).
The term ‘recurrent implantation failure’ is a subgroup of
recurrent IVF failure and should not be used to replace it.
What is implantation rate ?
number of embryos which have produced US evidence of
an intrauterine gestational sac per the total number of
embryos transferred into the uterine cavity (Zegers-Hochschild et
when day-2 or -3 embryos are transferred is about 25%,
But when day-5 or -6 embryos are transferred is usually
higher, about 40%.
Is chemical pregnancy considered as
Implantation failure refers to the failure of the embryo to
reach a stage when an IU gestational sac is recognized by
i.e: the only clinical evidence of implantation is appearance
of IU gestational sac .
The common defendants
(Angelini et al., 2006).
(Modi et al., 2012; Strowitzki et al., 2006)
(Karlstrom et al., 1997)
Age is the most important single variable affecting outcome
in ART. (Rosenwaks et al; 1995).
Effect on oocyte quality and endometrial receptivity ????
cause or prognosticator
Pregnancy depends on implantation of
a developmentally competent embryo to
dip in a receptive endometrium.
Establishing the relationship between soil/seed
Endometrium / embryoSoil/seed
•Endometriosis(1/3 of them has NK cell
•Immunological Factors (maternal
tolerance to the baby )
immunologic system plays a role in the
process of implantation, and in the
subsequent maintenance of pregnancy .
Chaouat et al; 2007
Singh et al 2011
• Gamete (Sperm DNA
• Zona Hardening
• Inadequate culture
Bad ET technique
previous IVF treatment cycles
drugs used during ovarian stimulation, number of oocytes
method used for fertilization, fertilization rate, embryo
day and ease of embryo transfer procedure
Counseling should precede the investigative process to:
ensure patients understand the rationale, potential benefit
and cost implications of the proposed tests.
information leaflets should augment the counseling process
High-resolution ultrasound scanning,
Screening for congenital and acquired thrombophilic
Evidence-based investigations should include :
Other commonly performed investigations with weaker
evidence base include :
karyotype analysis for the couple,
laparoscopy for diagnosis and treatment of endometriosis
endometrial biopsy. Has it had a place in modern practice??!!
The role of immunologic testing for natural killer cell
counts and cytotoxicity assay remains controversial.
• submucous fibroids (FIGO 0-2)
• endometritis .
Searching for correctable pathology in up to 45%
of patients with RIF.
Even in the absence of identifiable pathology, there is evidence that
performing hysteroscopy could still improve the likelihood of
pregnancy in the subsequent IVF cycle [El-Toukhy et al; 2008 systematic review
and metaanalysis ].
Hysteroscopic resection of the septum improves the
reproductive outcome of infertile women (Bakas et al., 2012;
Mollo et al., 2009).
• After polypectomy ??!!
patients can undergo ovarian stimulation after their next
menses after a polypectomy without affecting assisted
reproductive treatment outcomes (Pereira et al., 2016).
Postpone assisted reproductive treatment for 2 months
after hysteroscopic septoplasty and for 3 months after
myomectomy or adhesiolysis. Yang et al. (2013)
Does it affect IVF results ?
altered endometrial histology and a lack of expression of endometrial
adhesion molecules (integrins), which may play important roles in the
implantation process (Meyer et al; 1997).
Reflux of hydrosalpinx results in mechanical factors diminishing
embryonic endometrial apposition (Sharara 1999).
Hydrosalpinx fluid contains embryotoxic inflammatory compounds
(Mukherjee et al; 1996).
Two meta-analyses estimated that hydrosalpinges
diminished implantation rates by 35–50% And also
responsible for early pregnancy loss (Zeyneloglu et al; 1998 ,
Camus et al; 1999).
Laparoscopic salpingectomy or proximal tubal occlusion .
Options for management?
Bilateral salpingectomy results in improved implantation as
well as pregnancy rates compared with controls who
harbor hydrosalpinges (Bredkjaer et al; 1999). Dechaud et al 1998 ,
Strandell et al; 1999
All studies were done on females aged <39 years .
Improved pregnancy rates in patients who had
hydrosalpinges and underwent laparoscopic salpingectomy
after experiencing repeated implantation failure (Dechaud et
Complications of salpigectomy
salpingectomy prior to IVF may impair ovarian response.
Fan et al; 2016 Fetril Steril Meta-analysis
For women with diminished ovarian reserve either
interruption of tubal uterine patency or ultrasound-guided
drainage of hydrosalpinges might also be considered .
Endometrial scratching before IVF
• Mechanical manipulation was shown to be associated with
decidual formation in guinea pigs
• Endometrial scratching during the progestational phase of
estrous cycles provoked a rapid growth of decidual cells.
Loeb L. Zentralblatt fur allgemeine Pathologie und pathologische
Anatomie 18 563–565. 1907
The 1st evidence is
reported at the beginning
of the 20th century
In women with RIF , inducing local injury to the endometrium in
the cycle prior to starting ovarian stimulation for IVF can improve
pregnancy outcomes However, large studies are required before this
can be adopted in routine clinical practice. Potdar et al; 2012 a
systematic review and meta-analysis
Endometrial injury performed between day 7 of the previous cycle
and day 7 of the embryo transfer (ET) cycle is associated with an
improvement in live birth and clinical pregnancy rates in women
with more than two previous embryo transfers.
Not advised in day of oocyte retrieval as it was associated with a
reduction of clinical and ongoing pregnancy rates.
[Cochrane Database Syst Rev. 2015]
endometrial thickness or
pattern seem inadequate
where it seems difficult or
impossible to make it grow.
endometrial thickness under 7 mm would define a refractory
endometrium with compromised success rates (Dix and Check, 2010;
Kasius et al., 2014). Although prevalence is low (2.4% according to
Kasius et al., 2014), it still represents a challenge today.
Causes of refractory endometrium ??!!
dilation and curettage:
D & C a risk factor for adhesion formation (40% of cases o
IUA) (Hooker et al., 2014).
Congenital Müllerian anomalies
US assessment of endometrial receptivity of clinical
• Doppler assessment of uterine and spiral artery flow.
imaging technologies can provide information about endometrial
receptivity up to a certain stage, as pregnancies have been described
even in thin endometria <5 mm, as well as in hyperechogenic
So molecular technologies will help us to further understand
endometrial receptivity but still needs to be validated in a prospective
trials (Cruz and Bellver, 2014).
hypoechogenic endometrium was more receptive than the iso- or
hyperechogenic endometrium before hCG triggering. i.e progesterone
effect (Check et al., 1993)
no agreement has been reached on endometrial thickness. Although
most clinicians empirically prefer endometria >7 mm, available
evidence does not support any specific thickness, as pregnancies with
similar success have been described from 5 mm to more than 15 mm
(Cai et al., 2011; Remohn et al., 1997).
Endometrial thickness ??!!
Is their is minimal endometrial thickness
required to establish a clinical pregnancy
after ART ??!!
A triple line multilayered pattern seems to be associated with
conception cycles in IVF.
Dickey et al; Hum Reprod 1992 , Serafini et al; Ferti Steri 1998
women with CE show altered uterine contractility may
explain the symptoms related to CE and infertility (Pinto et al.,
Kasius et al; 2011 reported a 2.8% prevelance of
chronic endometritis among infertile women
Clinical relation between RIF and CE??
Hysteroscopy is reliable in diagnosing Chronic
endometritis and it can assess clinical effectiveness of
antibiotic therapy (Among 211 patients with CE diagnosed
by hysteroscopy, 200 cases were confirmed histologically)
(Guo et al; 2013).
(B) At histology
stroma of micropolyps is
characterized by an
(lymphocytes, plasma cells
or eosinophilic granulocytes)
intermingled with normal
stromal cells around small
vessels and glandular
Micropolps is considered a
reliable diagnostic sign for CE .
(Ettore et al; 2005).
Criteria proposed by Cicinilli et al; 2005 to establish
the diagnosis of chronic endometritis
• Hyperemia : the vascular pattern seen accentuated at the
• Stromal edema : if the endometrium examined during proliferative
phase it was seen thickened and pale
• Micropolyps : small vasecularized pedunculated protrusions of the
uterine mucosa <1mm (PPV 98.4%)
And they concluded that absence of stromal edema and hyperemia
has a (NPV 98.8%)
NB: presence of itrauterine synechia is a severe form on long term
sequalea of chronic endometritis ،األربعاء04،شعبان1437
No pathognomonic features !!!
While may be suspected by indirect features :
• Tender probing
• women with CE show altered endometrial patterns in both the periovulatory
and midluteal phases. (Pinto et al., 2015).
• Folliculo-endometrial asynchorony (increased endometrial thickness
asynchronous with follicular growth)
• Intracavitary synechiae ( 3D SIS ) ،األربعاء04،شعبان1437
Management of refractory endometrium
Medical therapeutic strategies
Evidenve with is lacking
Type in Market :
oestradiol valerate (Lignieres et al., 1986).
for up to 9 weeks with no adverse effects, such as endometrial
hyperplasia or bleeding. (Chen et al., 2006; Remohí et al., 1995).
(6 − 8 mg or up to 16 mg) continuously from cycle day 1, unless
tolerance is poor.
In general, 2 mg suffice to block HPO axis,
No value of progressive step-up increase in the dose that simulates a
natural cycle (Coughlan et al., 2014; Shen et al., 2013).
Q: does estrogen addition as an adjuvant to
progesterone in the luteal support of value or not ?
Estrogen increase clinical pregnancy rate
but its role in management of refractory
endometrium is still lacking an evidence
HCG injection in the proliferative phase
Where receptors of hCG present ?!
G-CSF supplementation modulated expression of genes
that play a role in endometrial vascular remodelling, local
immune regulation and cell adhesion (Rahmati et al., 2014).
Limited experience in women with recurrent miscarriage
(Santjohanser et al., 2013) and repeated implantation failure
(Wurfel et al., 2010) after undergoing IVF with G-CSF
supplementation is available.
when a well-designed, adequately powered, proper RCT
was done by the pioneers of this concept,
they were unable to demonstrate any effect of G-CSF on either
endometrial growth or pregnancy rates in women undergoing IVF
(Baradet al., 2014).
After wide application of doppler
US and assessment of
subendometrial blood flow
The patients who received aspirin showed a higher pregnancy rate
(18.4% versus 9%), as well as an improved endometrial pattern,
although the endometrial thickness and uterine vascular flow
parameters remained unchanged (Hsieh et al., 2000).
Use of LDA to improve pregnancy rate in patients
undergoing IVF treatment if not supported .
Dentali et al; 2012
Meta analysis – systematic review
synthetic derivate of methylated xanthine
Mechanism of action:
VD-increased RBCs deformability
800 mg pentoxifyllin plus 1000 IU vitamin E for 6 − 8 months
Its administration is associated with increased ET (Letur-Konirsch and
Delanian, 2003). Acharya et al. (2009)
Effect is enhanced when co-administered with vitamin E (Chiao and
Administration should be suspended before ET
There is no current evidence to support the use of nitroglycerin
patches in women with a thin endometrium.
Nitric oxide (NO) is involved in endometrial cycle control and uterine
preparation for pregnancy.
Sildenafil citrate is a selective inhibitor of 5-phosphodiesterase, the
enzyme that hydrolyses cGMP.
Mode of action:
• enhances the vasodilator effect of nitric oxide by reducing cGMP
• endometrial growth facilitating effect
• reduce natural killer cell activity, which may be of interest for
women with recurrent miscarriages (Jerzak et al., 2008).
25 mg/6 h in vaginal suppositories in the proliferative
phase, and administration was stopped prior to HCG
administration or embryo transfer. Sher and Fisch (2000)
Zinger et al. (2006) described two successful cases in women with
endometrial epithelial cell
culture has been reported to
have a very moderate effect on
cell proliferation, but no
significant changes were found
in nitric oxide concentrations
(Khazaei et al., 2011).
So although biological conflict with the clinical evidence exists, any
evidence for the clinical benefit of sildenafil in women with a
recurrent thin endometrium is weak, and very few publications on
non-randomized studies have been found, with very few patients
No benefit of sildenafil on
endometrial growth in a
study Check et al. (2004) .
According to Qublan et al. (2008), the administration of
GnRH (triptorelin, 0.1 mg on the day of oocyte retrieval, day of
embryo transfer and 3 days later) plus conventional luteal phase
support significantly improved implantation and
pregnancy rates. However, no other study has validated
Luteal phase GnRH agonists in cases of RIF
A RCT done by Simin et al; 2015 concluded that in addition to
routine luteal phase support using progesterone, administration of
0.1 mg of Decapeptil 6 days after oocyte retrieval in women with
previous history of 2 or more IVF/ICSI failures led to a significant
improvement in implantation and pregnancy rates after ICSI
following ovarian stimulation with GnRH antagonist protocol.
In a meta-analysis evaluating Administration of single-dose
GnRH agonist in the luteal phase in ICSI cycles. (Oliveira et al; 2010)
they conclude that:
luteal-phase single-dose GnRH-a administration can increase
implantation rate in all cycles and CPR per transfer and ongoing
pregnancy rate in cycles with GnRH antagonist ovarian
Misdirected immune response when an immune
system attacks its own tissues .
• Alloimmunity :
The immune system attacks foreigen tissues from the
same species e.g: graft rejection
More than 85% of immunological
causes of RIF is autoimmune in
Autoimmune implantation dysfunction
• Rhumatoid arthritis
• Hashimoto thyroidiits
Secondary ( Reactionary )
All are associated with increased levels of
ANA ( relation to RIF or RPL) ???!!
Enhance phspholipid production by trophoblast
Repel APA production from trophoblast
Decrease platelet adhesiveness
• Intralipids >>>>>>>> aNK suppressors
• Immunoglobulins (IVIG) very expensive , many risks
• Dexamethazone/Prednisone >>>>>>>>>> CTL suppressors
Twice dailty 14 days before ET day till 10th week gestation
• Others ( LIT/Humera/Aspirins)
Intralipid 20% ??!!
Routinely used for parenteral nutrition, intralipid is a fat emulsion
that was reported to suppress abnormal NK cytotoxic activity in
peripheral NK cells from women with recurrent reproductive failure
both in vitro and in vivo Roussev et al; 2008
1000ml contain (purified soybean oil 100g, purified egg phospholipids 12g,
glycerol anhydrous 22g, water for injection.
It is composed of 10% soybean oil, 1.2 % egg yolk phospholipids, 2.25 % gylcerine
2g of fat/kg body weight/day (20ml, 10ml and 6.7ml/kg of intralipid 10%, 20% and
The drip rate is about 2 to 3 ml/min for intralipid 10%. It should be started at half
the infusion rate during the first 30mins under supervision.
• 7-14 days prior to ET
• Repeated on the day of ET
• Repeated again with a positive pregnancy test and administer
every month until the 20th week
propofol is widely used, and in volume doses that are higher than
those suggested for the treatment of RIF.
many IVF programs, perform egg retrieval by
general anaesthesia, applying propofol as a short
acting hypnotic agent. Propofol solution contains
the same components of intralipid emulsion (10 %
soybean oil, and 1.2 % purified egg phospholipid,
with 2.25 % glycerol), supplemented with 1 %
Role of IVIG
The only properly conducted prospective RCT by
stephenson & Flucker (2000) involving 51 women with 2
or more IVF failure showed IVIG of no benefit .
Role of steroids
A meta analysis of 13 RCT by Boomsma et al ( Cochrane
data base 2007 ) showed no evidencing benefit routine
use of steroids in women undergoing IVF.
Empiric use of Aspirin
• No benefit in cases of RIF ( Gelbaya et al Hum Reprod 2007 )
• Two studies showed higher prevalence of ACA in
women with RIF ( Kaider et al 1996 & Qublan et al 2006 ) .
• However the only RCT in the use of LDA or/ Heparin in
cases of high levels of ACA shows no benefit in cases of
RIF (stern et al 2003 ).
Alloimmune implantation dysfunction
Repeated exposures to matching implanting embryos lead
to NK cells activation that become permanent.
Screening for Inherited and acquired
when summarizing all studies focusing on gene
polymorphisms and the thrombophilia trait, it seems that
prothrombotic disorders are more prevalent in RIF
patients than in controls [Toth et al; 2011].
Relation between thrombophilia and RIF
While , empiric treatment with heparin is not justifiable .
Altogether, it is recommended that patients diagnosed with
RIF be investigated for acquired as well as hereditary
thrombophilia disorders , and be treated accordingly.
Berker et al; 2011
Seshadri et al; 2011
Urman et al; 2009
serum testing for congenital and acquired thrombophilia
could be useful in identifying patients who could benefit
from adjuvant LMWH and low dose aspirin [Qublan et al; 2008].
What about empiric use of LMWH in ART patients ?
Genetic factors PGD ??
• Number transferred
• Stage of development
• Storage protocol
IVM-IVF as an alternative in cases of repeated IVF failure ???
Rate limiting step in human reproduction !
Is morphological grading is sufficient !!
Embryonic interventions that may improve IVF
Pre implantation genetic diagnosis and other
methods for embryo selection
preimplantation genetic screening (PGS) ….. Time lapse imaging
Not suitable for all patients: ??
• to patients who are younger in age and produce over six
oocytes.[Levitas et al; 2004].
activation of the embryonic genome occurs at the eight- to
10-cell stage (day 3 of culture).
Embryos that cleave after day 3 in culture therefore are no
longer dependent on maternal RNA transcripts and
have made the successful transition from maternal to
embryonic genomic control.
Why blastocyst is more competent ?
Q : Is blastocyst transfer is a successful
treatment in cases of RIF?
live birth after fresh IVF is significantly higher after
blastocyst-stage embryo transfer as compared to cleavage-
stage embryo transfer when equal number of embryos are
transferred in the two groups compared. Papanikolaou et al;
2008 systematic review and meta-analysis
Assissted hatching (AH)
It was also noted that cleavage-stage embryos with a reduced zona
thickness seemed to have a good prognosis for implantation (Cohen et
Mechanical or with a piezo-micromanipulator (Nakayama et al;1998) or
by laser (Hsieh et al; 2002).
• Direct damage to blastomeres-Incomplete hatching-Premature
AH was related to increased clinical pregnancy and multiple
pregnancy rates in women with RIF.
Das et al; 2009 Cochrane review
Meta-analysis 2011 Martins et al
AH slightly improves clinical pregnancy rates, particularly in poor
prognosis patients, including those with RIF, Poor quality embryo and
Older women (38 or more), while routine practice is not supported .
ASRM 2007 committee opinion
Extraordinary genetic diversity of the
human embryos at implantation
That put another question about the
value of PGS before embryo transfer
Is it a help or a hype
Available evince of does not support the use of PGS for
patients with RIF. ASRM committee opinion 2007
What about 2nd generation PGS ???
Whole genome amplification (WGA)
Hyaluron enriched embryo transfer medium (EmbryoGlue)
In 42 women undergoing IVF, embryos were transferred
into 50 μL of EmbryoGlue for 10 min prior to transfer
inside uterine cavity. In the control group (n = 42),
embryos were transferred to conventional blastocyst
in patients with recurrent implantation failure, it may be
considered as a useful transfer medium Neeta et al; 2015.
Evidence suggests improved clinical pregnancy and live
birth rates with the use of functional concentrations of
EmbryoGlue as an adherence compound in ART cycles.
However, the evidence obtained is of moderate quality. The
increase in multiple pregnancy rate may be the result of
use of a combination of an adherence compound and a
policy of transferring more than one embryo. Further
studies of adherence compounds with single embryo
transfer need to be undertaken. Cochrane review 2015
Two tests encountered with cases of RIF !!
Sperm Chromatin Structure Assay (SCSA):
Sperm chromatin dispersion test (SCD)
DNA fragmentation index >27%: RIF (Larson et al.,2000; Larson-Cook
et al., 2003)
Sperm as a cause of RIF ?
sperm DNA fragmentation is not an important cause of
RIF and there is a significant differences between test
methodologies in interpreting the data . Carol et al ; 2015
SDF is not related to chromosomal anomalies in embryos
from patients with implantation failure. Furthermore, the
different methods used to evaluate DNA fragmentation may
produce different results. F. Bronet human reprod 2012
The results of DNA testing alone can not predict reproductive
outcome in patients of ART
IMSI is a real-time method where sperm is selected before
the microinjection takes place to identify spermatozoa
devoid of surface vacuoles.
By using an inverted microscope that is able to provide
much greater magnifying power (around 6000 times) than
that normally used in reproductive laboratories (400 times)
to carry out ICSI
(Bartoov et al., 2003).
The only confirmed indication for IMSI is RIF while routine
use in IVF practice still not recommended . (Boitrelle et al,
as a cause of IVF failure
• Mock transfer in prior cycles ???
Introducing infection ?? Better to map your transfer technique before
• Full Bladder ???
• US guidance
Their in no excuse for non US guided ET
• Sequential embryo transfer
• Interval double ET (on days 2 and 4 or 5): improves CPR
Is FET cycles is an easy and good
Vitrification is Ultra-Rapid freezing method the keep the
biological and chromosomal integrity of the embryo
Frozen Embryo Transfer Baby, born January
1991, now age 21. Michael with his mum,
One in 4 females has displaced window of
implantation so need PET and ERA test
Personalized embryo transfer (pET)
ERA test to determine endometrium is receptive or not
pET performed on the day designated by the ERA: 50.0%
PR and 38.5% IR (Ruiz-Alonso et al, 2013).
• Many known and unknown reasons for RIF, and we do not have
the tools to diagnose in each case the exact cause.
• The management of RIF should be individualized
IU administration of autologous
PBMC Peripheral blood mononuclear cell
Salpingectomy for tubal disease
RCT: Not or may not beneficial
Aspirin, heparin, IVIG
intralipid does not have a
clear impact on ttt outcome.
Co cultures, sildenafil,
transfer of six embryos,
natural IVF, and PGS await
further clinical assessment.