Post on 24-Dec-2015
Sticky surface: a scientific review of
endometrial receptivity
Prof. Juan A Garcia-Velasco IVI – MadridRey Juan Carlos UniversityMadrid – Spain
Limiting factor in achieving pregnancy Multiples embryos transferred:
no implantation? multiple pregnancy?
Poorly understood
Endometrial receptivity
“Restricted time-related period when the uterus is receptive to blastocyst attachment & invasion”
Concept of WOI – window of implantation Temporally frames the period of receptivity 4-5 day interval with peak Progesterone levels Synchrony between embryo and endometrium Opens day 19/20 by loss of epithelial E2 & P receptors
Endometrial receptivity
Revel F&S 2012
E 17 18 19 20 21 22 23
P P+4 P+5 P+6 P+7 P+8 P+9 P+10
Endometrial receptivity
Embryos attach ONLY underoptimal conditions
When to start progesterone?
TIMING is relevant
IHC Chromatography RT-PCR DNA microarrays microRNAs Proteomics Secretomics ……..
How to assess ER today?
Noyes et al. Fertil Steril 1950
-accuracy?-reproducibility?-clinical utility?
Endometrial dating – fertility status?
Doses for COS (AMH, BMI, age….) Type of protocol IVF vs ICSI Embryo number and quality ………
Personalized Medicine
However:endometrial status at ET is treated equallyneglected customized approachlack of knowledge?
Embryo transfer TIMING can be personalized
Technology helps
Transcriptome Proteome Metabolome
The age of –OMICS
Different subtypes of disease
TRANSCRIPTION TRANSDUCTION
Transcription regulation
Alternative splicing
Transduction regulation
DNA RNA mRNA Protein METABOLITES
JCEM
MHR
MHR
HR
JCEM
Horcajadas JA, Pellicer A, Simón C. Hum Reprod Update 2007.
Endometrial Receptivity Array (ERA)
Customized microarray
Bioinformatic analysis of data obtained by the customized microarray
Classification and prediction from gene expression.
Predictors: Characterization of RECEPTIVITY transcriptome
Endometrial Receptivity Array (ERA)
.
Receptive Profile
..
IF Sample NR1
.
Post-Recep Pre-Receptive
Receptive
Non Receptive samples
Proliferativ
e
Predictor classifies the molecular receptivity status of the endometrium
E :6 mg/day
P :800 mg/day
2
4
NATURAL CYCLE
Endometrial biopsy must be taken on the 7th day after the LH surge (LH+7)
urine or serum preferible
HORMONE REPLACEMENT THERAPY CYCLE
Endometrial biopsy must be taken on day P+5, after proper E2 priming
Endometrial Receptivity Array (ERA) - Timing of the biopsy
Direito A, et al. Fertil Steril 2013
LH surge variantsExtremely variable LH surges in configuration, amplitude and duration
Short Medium
Double Prolonged
Single Plateau
Double Multiple
Direito A, et al. Fertil Steril 2013
LH surge variantsWhen does ovulation happen according to LH surge?
Onset During
End After
Pathologist 1 (P1) Pathologist 2 (P2) P1 vs P2 ERA
Kappa value 0.618 (0.446-0.791) 0.685 (0.545-0.824) 0.622 (0.435-0.839) 0.922 (0.815-1.000)
0.61 - 0.80 - Good Concordance0.81 - 1.00 - Very Good Concordance
In a blinded study ERA classifies better than Noyes criteria
Endometrial Receptivity Array (ERA) – Accuracy
Díaz-Gimeno P, et al. Fertil Steril 2013
ERA TEST ANALYZED IN THE SAME PATIENT in two endometrial biopsies up 2-years apart
Endometrial Receptivity Array (ERA) – Consistency
Code Date First Biopsy
Date Second Biopsy
Months between
First Biopsy Results
Second Biopsy Results
CON1 09/2009 02/2012 29 Receptive Receptive (0.908)
CON2 09/2009 03/2012 30 Receptive Receptive (0.908)
CON3 05/2009 04/2012 35 Receptive Receptive (0.908)
CON4 05/2009 05/2012 36 Proliferative Non Receptive (0.864)
CON5 01/2009 05/2012 40 Proliferative Non Receptive (0.864)
CON6 07/2009 05/2012 35 Receptive Receptive (0.908)
Díaz-Gimeno P, et al. Fertil Steril 2013
Ruiz-Alonso M, et al. Fertil Steril 2013
Ruiz-Alonso M, et al. Fertil Steril 2013
0
10
20
30
40
50
60
70
80
IR
PR
Rate
(%
)
Months after ERA test 1 2 3 4 5 6Number of patients 91 87 47 30 15 40Implantation Rate (%) 37.9 43.1 44.6 45.8 58.3 48.6Pregnancy Rate (%) 54.9 59.8 55.3 53.3 73.3 70.0
First pET outcome after RECEPTIVE ERAin RIF patients (n=310)
No relationship with endometrial biopsy
Ruiz-Alonso M, et al. Fertil Steril 2013
Progesterone
EpithelialPR
Window of Endometrial Receptivity (WOI)
P P+1 P+2 P+3 P+4 P+5 P+6 P+7 P+8 P+9
ERA clinical applicabilityA case report and pilot study comparing routine embryo transfer versus pET
(Ruiz-Alonso et al. 2014 Hum Reprod 2014).
8. OD with pET using day-5 blastocysts in HRT cycle after 7 days of progesterone (P+7) Succesful twin pregnancy
Ruiz-Alonso, et al. 2014
DIAGNOSTIC INTERVENTION ERApre-receptive at P+5, being receptive at P+7
CASE REPORT
ART treatments in our center
3. IVF with fresh day-5 ET 4. IVF with differed day -5 ET in natural cycle 5. OD with day-3 ET in HRT cycle (P+3) 6. OD with day-3 ET in natural cycle 7. OD with day-5 ET in HRT cycle (P+5)
Routine work-up negative 1. IVF with fresh day-3 ET 2. IVF with fresh day-3 ETPrevious ART treatments
CLINICAL OUTCOMEET
Number of patients 17Source of oocytes Ovum donationAge 40.7 ± 4.7 (32-49)Number of embryos transferred 1.8 ± 0.4Implantation rate 12.9% (4/31)Pregnancy rate 23.5% (4/17)Ongoing pregnancy rate 0% (0/4)Clinical abortion 100% (4/4)Biochemical pregnancy 0.0% (0/4)Total attempts 2.1 ± 1.3Number of embryos transferred 1.8 ± 0.4Implantation rate 10.8% (7/65)Pregnancy rate 19.4% (7/36)Ongoing pregnancy rate 0% (0/7)Clinical abortion 71.4% (5/7)Biochemical pregnancy 28.6% (2/7)
Firs
t att
empt
Cum
ulati
ve
Ruiz-Alonso, et al. 2014
CLINICAL OUTCOMEET
Number of patients 17Source of oocytes Ovum donationAge 40.7 ± 4.7 (32-49)Number of embryos transferred 1.8 ± 0.4Implantation rate 12.9% (4/31)Pregnancy rate 23.5% (4/17)Ongoing pregnancy rate 0% (0/4)Clinical abortion 100% (4/4)Biochemical pregnancy 0.0% (0/4)Total attempts 2.1 ± 1.3Number of embryos transferred 1.8 ± 0.4Implantation rate 10.8% (7/65)Pregnancy rate 19.4% (7/36)Ongoing pregnancy rate 0% (0/7)Clinical abortion 71.4% (5/7)Biochemical pregnancy 28.6% (2/7)
ENDOMETRIAL RECEPTIVITY DIAGNOSIS USING ERAET
Receptive 0% (0/17)Pre-receptive 94% (16/17) WOI delayed 1 day 19% (3/16) WOI delayed 2 days 81% (13/16)Post-receptive 6% (1/17) WOI advanced 1 day 100% (1/1)
Firs
t att
empt
Cum
ulati
ve
CLINICAL OUTCOMEET pET
Number of patients 17Source of oocytes Ovum donationAge 40.7 ± 4.7 (32-49)Number of embryos transferred 1.8 ± 0.4 1.7 ± 0.5Implantation rate 12.9% (4/31) 34.5% (10/29)Pregnancy rate 23.5% (4/17) 52.9% (9/17)Ongoing pregnancy rate 0% (0/4) 32.3% (6/17)Clinical abortion 100% (4/4) 0% (0/9)Biochemical pregnancy 0.0% (0/4) 17.6% (3/17)Total attempts 2.1 ± 1.3 1.2 ± 0.4Number of embryos transferred 1.8 ± 0.4 1.8 ± 0.4Implantation rate 10.8% (7/65) 40.0% (14/35)Pregnancy rate 19.4% (7/36) 60.0% (12/20)Ongoing pregnancy rate 0% (0/7) 45.0% (9/20)Clinical abortion 71.4% (5/7) 0% (0/12)Biochemical pregnancy 28.6% (2/7) 15.0% (3/20)
ENDOMETRIAL RECEPTIVITY DIAGNOSIS USING ERAET
Receptive 0% (0/17)Pre-receptive 94% (16/17) WOI delayed 1 day 19% (3/16) WOI delayed 2 days 81% (13/16)Post-receptive 6% (1/17) WOI advanced 1 day 100% (1/1)
Firs
t att
empt
Cum
ulati
ve
IVF Patients
ReproductiveFollow-up
ReproductiveFollow-up
pET vs. ET
Group C Biopsy & ERA
N= 814
Report
Group AET in COS
N= 814
Group BET in HRT
N= 814
ReproductiveFollow-up
ReFollow-upproductive
Randomization
ET in COS vs.
ET in HRT
ReceptiveN= 732
Non-receptiveN= 82
Randomization
Randomized, multicenter, international clinical trial
Group C (NR1) pET in HRT
N= 41
Group C (R) pET in HRT
N= 732
Group C (NR2)ET in HRT
N= 41
ReproductiveFollow-up
Stanford UniversityCalifornia, USA
IVI MEXICOIECH Monterrey IVI PANAMA
FertilityHuntingtonUSP Sao PaoloBRASIL
IVI SPAIN
Fertility center, Brussels, BELGIUMVersys clinics,Budapest,
HUNGARYSbalagrm Sofia,BULGARY
Bahceci health group Istambul,TURKEY
ERA RCT EN EL MUNDO: 21 CENTROS
KKH,SINGAPORE
Hannam IVF TorontoCANADA
Seoul Maria HospitalSOUTH KOREA
Genesis IVF, SERBIA
Non-invasive diagnostic methods for the endometrial factor based on secretomics of the EFg
Cytokines
Signaling Factors
Proteins
ChemokinesProstaglandins
miRNAs
Glycoproteins
Salamonsen 2012
Simon 2010Matorras 2011
Greenblatt 2011
Simon 2013Hamamah 2013
Vilella, et al. 2013
*(p<0.05)**(p<0.01)
*
**
PGs LEVELS IN EF OBTAINED 24H BEFORE DAY 3 ET
PGE2
PGF2a
Con
cent
ratio
n (n
mol
/g)
Vilella, et al. 2013
PGs LEVELS IN EF OBTAINED 24H BEFORE DAY 5 ET C
once
ntra
tion
(nm
ol/g
)
PGE2
PGF2a
Vilella, et al. 2013
The transcriptomic signature of endometrial receptivity (ERA
test) revealed that the endometrial factor is responsible for
25% of cases of patients with RIF.
Personalized Embryo Transfer (pET) normalized clinical
results.
We will be able to investigate ER through novel non-invasive
biomarkers, such as lipidomics (PG´s) in endometrial
secretions
Conclusions
juan.garcia.velasco@ivi.es
Thank you!