Recurrent implantation failure (RIF) is defined
as the lack of any pregnancy in three consecutive
In recent years, great advances have been
achieved in the treatment of infertile couples.
However despite these advances, there are still
some infertile couples who suffer from RIF.
Probable underlying etiologies for RIF are aneuploidy
of embryos, uterine cavity abnormalities,
diminished endometrial response, and insufficiencies
in transfer techniques (
Our aim was to investigate the characteristics of our patients who suffer from RIF and to discuss the management protocols in view of the literature.
In this cross sectional study, patients who underwent IVF/ICSI cycles at İstanbul University Cerrahpasa School of Medicine, Department of Obstetrics and Gynecology, IVF Unit from January 2000-January 2007 were retrospectively reviewed to locate those patients diagnosed with RIF. A total of 1822 cases out of 2183 were included in the study. Of these, 185 RIF patients were compared to 1637 patients who did not have RIF. Patients with cycle cancellation and no oocyte during oocyte pick up or men without sperm at TESE were all excluded from the study. The inclusion criteria was: age limit of 42 years, basal follicle stimulation hormone (FSH) (day 3) level of <20 mIU/mL, and normal gynecological ultrasound and cervical smear. All patients were given a written informed consent. The local Institutional Ethics Committee approved the study.
All patients received the GnRH agonist leuprolide acetate (1 mg/day sc Lucrin®, Abbott- France Pharmaceuticals, France) beginning on the 21st day the of previous cycle (long protocol) or the first day of the cycle (short protocol). Leuprolide acetate was reduced to 0.5 mg/day and gonadotropin 150-450 IU (Menogon®, Ferring, Istanbul; Gonal F®, Merck Serono, Istanbul; or Puregon®, Schering Plough, Istanbul, Turkey) were initiated on the third day of menstruation according to age, body mass index (BMI), basal FSH value, and prior ovulation induction trials.
Controlled ovarian hyperstimulation (COH) was monitored by transvaginal sonography, and the gonadotropin dose was adjusted according to follicle size and number. When three or more follicles reached >18 mm, we administered 10000 IU of human chorionic gonadotropin (hCG, Pregnyl®, Schering Plough, Istanbul, Turkey) for ovulation induction.
Oocyte aspiration was performed transvaginally, 35-36 hours after administration of the hCG injection. During the oocyte pick-up procedure, sedative anesthetics or local anesthesia was used. Sequential medium was used for embryo culture and transfer. Embryos were selected for transfer by pronuclei scoring, cleavage rate, fragmentation, and blastomere equivalence scoring. Assisted hatching was applied to embryos which had thick zona pellucida layers. Quality of embryos and age of the patients were the main factors in determining the number of embryos to be transferred. Hard manipulations, bleeding from cervix during the transfer procedure, or the use of a tenaculum were considered "difficult transfer".
The luteal phase was supported by progesterone (200 mg, Progynex®, Koçak, Istanbul, or Crinone gel® 8%, Merck Serono, Istanbul) administered vaginally three times daily or 100 mg progesterone IM injections daily (Progynex ® ampule, Koçak, Istanbul). In appropriate cases, embryos were followed until the blastocyst phase and transfer was performed at that time. Clinical pregnancy was defined as the detection of a gestational sac on the ultrasound. Implantation rate was defined as the number of gestational sacs over the number of embryos transferred. Pregnancy rate was defined as the number of pregnancies with visible fetal heart activity on ultrasound examination over the number of transferred embryos.
Results were expressed as mean ± SD, frequency, and percentages. Analyses were performed by Unistat 5.1 software. Categorical characteristics of patients were compared with the chi square test. Independent Samples t-test and Mann Whitney U tests were used for comparison of numeric variables. P<0.05 was considered statistically significant.
In our study, 589 couples achieved pregnancy out of 1822 (32%). Implantation rates were as follows: 10% (first attempt; n=1424); 9.6% (second attempt; n=435); 11% (third attempt; n=201); 5.8% (fourth attempt; n=91); 2% (fifth attempt; n=41), and 6% for >5 attempts (n=75). Success rates diminished significantly after the third attempt.
According to age, implantation and pregnancy rates were 10% and 29.5% under 35 years; implantation rate was 7% and pregnancy rate was 25.7% between 35-39 years while implantation rate was 2% and pregnancy rate was 12.8% over 40 years.
Subjects had the following diagnoses: tuboperitoneal
factor (314), male factor (1320),
polycystic ovary syndrome (PCOS, 115), unexplained
infertility (50), hypogonadotropic
Etiology of the infertile patients
|Infertility etiology||Number (n)|
The group characteristics and results have been given in table 2. Non-RIF patients constitute group I, which included 1637 cases. Group II comprised 185 cases of RIF. The mean age was 32.48 ± 5.24 years in group I and 35.93 ± 4.76 years in group II (p<0.0001). Mean duration of infertility was 8.25 ± 5.05 years in group I and 11.04 ± 5.30 years in group II (p<0.0001). The mean weight of subjects in group I was 65.92 ± 10.85 kg and 69.85 ± 11.52 kg in group II (p<0.003). Mean values for waist circumferences were 82.88 ± 10.89 cm in group I and 88.12 ± 12.89 cm in group II (p<0.016).
Group’s characteristics and treatment features
|Group I (≤3 attempts)||Group II (>3 attempts)||P value|
|32.48± 5.24||35.93± 4.76||0.0001|
|8.25 ± 5.05||11.04 ± 5.30||0.0001|
|65.92± 10.85||69.85± 11.52||0.003|
|82.88± 10.12||88.12± 12.89||0.016|
|7.45 ± 3.86||8.95 ± 6.55||0.0001|
|29.85± 13.93||37.93± 15.30||0.0001|
|10.27 ± 2.45||11.33 ± 1.28||ns|
|2391.45 ± 1209||2989.02 ± 1262||0.0001|
|2001.95 ± 1617.75||1621.47 ± 1184.36||0.003|
|0.96 ± 0.63||3.37 ± 1.48||0.001|
|4.1 ± 3.5||3.9 ± 3.9||ns|
|3.49 ± 1.49||3.27 ± 1.65||0.045|
|66.00 ± 23.36||72.32 ± 20.15||0.001|
|3.00 ± 2.19||3.81 ± 2.27||0.0001|
ns; Not significant.
Day 3 FSH values were 7.45 ± 3.86 IU/ml in group I and 8.95 ± 6.55 IU/ml in group II (p<0.0001). The total number of 75 IU gonadotropin ampules administered was 29.85 ± 13.93 in group I and 37.93 ± 15.30 in group II (p<0.0001). Total gonadotropin dose was 2392.45 ± 1209.49 IU in group I and 2989 ± 1262.37 IU in group II (p<0.0001).
Estradiol (E2) values on hCG day were 2001.95 ± 1617.75 pg/ml in the first group and 1621.47 ± 1184.36 pg/ml in the second group (p<0.003). The mean value of serum progesterone level on the hCG day was 0.96 ± 0.63 ng/ml in group I and 3.37 ± 1.48 ng/ml in group II (p<0.001).
The mean number of MII oocytes were 4.1 ± 3.5 in group I and 3.9 ± 3.9 in group II; there was no statistical significance between groups. The mean endometrial thicknesses were 10.27 ± 2.45 mm in group I and 11.33 ± 1.28 mm in group II, which was not statistically significant.
The mean number of fertilized oocytes were 4.78 ± 3.05 in the non-RIF group and 4.13 ± 2.95 in the RIF group (p<0.006). The number of transferred embryos was 3.49 ± 1.4 in the non-RIF and 3.27 ± 1.65 in the RIF group (p<0.045).
Blastocyst transfers were done in 18 patients in group I and 7 patients in group II. The mean number of transferred blastocysts were 2 ± 1.32 in group I and 3.14 ± 0.69 in group II (p<0.043). Assisted hatching was applied to 19 patients in group I and 8 patients in group II.
According to Kruger’s criteria, the sperm parameter morphology was 3.81 ± 2.27 % (group II) vs. 3 ± 2.19 % (group I) and motility was 72.32 ± 20.15% (group II) vs. 66 ± 23.36% (group I) (p<0.001).The values were found to be significantly better in the RİF group.
The groups were also compared for singleton and multiple pregnancies. In the first group, rates for singleton pregnancies were 13.5%, twin were 5.4%, and triple were 1.9%, while they were 8.5% (single), 3.5% (twin), and 0.5% (triple) in the second group. Multiple pregnancy rates were lower in the RIF group compared to the non-RIF group.
Embryo transfer was classified into easy and difficult transfers. In group I the transfer was easy in 91.6% of cases, and in group II it was easy in 92.9% of cases. The transfer technique was not significant between the groups. Ultrasonography was used in 52.3% of the transfers in group I and 44% of the transfers in group II; there was no significant difference.
Group’s pregnancy rates
|Pregnancy rates||Group I (≤3 attempts)||Group II (>3 attempts)||P value|
Recurrent IVF failure continues to be an important
problem and a distressing condition for couples.
Despite recent advances in medical technology, implantation
rates still remain low. Our implantation
rate was reported as 10% for the first attempt and
diminished significantly after the third attempt. As
noted in the literature, implantation and pregnancy
rates decrease after the fourth attempt (
In our study, we found that the RIF group consisted of women with poor prognoses. In contrast, sperm morphology and motility were better in that group. Severe male factor was treated successfully in the first attempts, as they were probably married to normal fertile women.
Women in the RIF group had advanced mean age, higher day 3 FSH levels, longer infertility durations, and a higher mean weight when compared to non-RIF women. These differences were all statistically significant and can be defined as poor prognoses factors for women who underwent IVF.
It has long been known that with increasing age
there is a decline in natural fecundity and pregnanacy
rates. Along with the decrease in follicle
number, the oocyte quality also diminishes (
In recent decades, numerous reports regarding
the outcome of ART treatment have confirmed that
the probability of a live birth decreases distinctly after the age of 35 years (
Walsh et al. stated that couples with RIF had
poor prognosis and the pregnancy rates decreased
further over the age of 35 (
In our study the mean age of the RIF group was
35.93 years, which was older than the non-RIF
group. Maheshwari et al. have concluded that
older women were more likely to have a diagnosis
of unexplained infertility compared with
those who were younger. They also reported that
the duration of infertility was more widespread
in older women, which was compatible with our
Both increasing age and basal FSH were significantly
associated with reduced numbers of oocytes
collected, oocytes fertilized, and embryos
transferred. Markers of ovarian reserve, day 3
FSH, inhibin B and E2, anti-müllerian hormon
(AMH), antral follicle count (AFC) are particularly
predictive and useful in guiding the choice
of the optimal protocol for ART. However, no
tests have been absolutely predictive of a successful
outcome. Today there is no technology
that can predict the IVF outcome or estimate the
RIF group (
In our study we found a statistically significant
difference for weight between the two groups in
favor of the non-RIF group. The published data
regarding the effect of body mass index (BMI)
on IVF cycles is varied. Some studies highlighted
a state of gonadotropin resistance in obese
women, which lead to higher gonadotropin requirement
for COH (
In our study the numbers of metaphase II oocytes obtained were similar in both groups, but in the RIF group we used a higher amount of gonadotropin and a lower mean level of E2 on hCG day was calculated.
Kably Ambe et al. have shown that E2 levels
on hCG day is not an influential factor on pregnancy
rates, especially in older patients (
In our study the serum progesterone level on
the hCG day was higher in the RIF group due
to early luteinization. Early luteinization incidence
varies, ranging between 5% and 30% in
IVF patients. It may adversely affect the clinical
outcome and could be related to diminished
ovarian reserve. It is not necessarily a LH-de
pendent event and is observed mostly in women
of advanced age (
Concurrent to our study, Ozturk Turhan et
al. have reported that in the group whose progesterone
levels were higher than 1.5 ng/ml
on the hCG day, mature oocytes, fertilization,
and cleavage rates were significantly lower
Early luteinization leads to more post-mature oocytes at oocyte pick-up and higher progesterone levels disturb endometrial maturation and integrity. Furthermore, fewer oocytes are fertilized and go under cleavage. As a result, the progesterone level has been shown to be higher in the RIF group and the mean number of transferred oocytes was lower compared to the non- RIF group.
Sperm count and motility were better in the RIF group, which lead us to conclude that our RIF patients constituted abundant, poor responder women and accordingly we needed to obtain better quality oocytes and prevent premature luteinization.
We measured endometrial thickness on
the hCG day and did not find any difference.
Richter et al. stated that thicker endometrium
increased clinical pregnancy, continuing pregnancy
and live birth rates independent from
age and embryo quality (
In our study, more embryos were transferred
in patients without RIF. They also had a greater
number of embryos available for transfer,
which was statistically significant (p<0.024). In
IVF procedures, the embryo number to be transferred
is increased when the patient has adverse
prognostic factors such as higher age, poor
embryo quality, and RIF. Fewer embryos are
transferred in couples with secondary infertility
that already have healthy children. Although it
is the usual practice to transfer three embryos
in Turkey, in couples who obviously have a
better prognosis single embryo transfer is the
treatment of choice. Frequently up to three embryos
could be transferred in the presence of
advanced maternal age and/or poor embryo
quality. However, even in the presence of an
obviously positive prognosis, more than half of
the physicians prefer to transfer three embryos,
and the percentage of doctors choosing single
embryo transfer has remained below 15% (
The guidelines published in 2006 emphasized
that embryo transfers yielded more successful
outcomes if they were performed at the blastocyst
stage in IVF cycles in order to reduce and prevent
multiple pregnancies. It has been determined essential
to transfer one or two embryos for those
under 35 years old, a maximum of three embryos
for those between 35-37, three embryos between
38-39, and four embryos for those over 39 years
of age (
In order to increase implantation rate, more
blastocysts were formed and transferred in the
RIF group. Transferring the embryos in blastocyst
stage resulted in higher implantation and
live birth rates in the RIF group (
The practice of assisted hatching was more frequent
in the non-RIF group. Sallam et al. concluded
that assisted hatching increased the rates of ongoing
pregnancy, implantation and pregnany (
As recommended in the literature, in our unit blastocyst transfer is preferred in appropriate patients, assisted hatching is used for thick zona pellucidas, embryo quality is evaluated by embryo scoring systems, and embryos of the highest quality are transferred, in order to have a better implantation and pregnancy rate.
In the literature, ulitrasound-guided embryo
transfer was associated with increased rates of
clinical, ongoing, and live pregnancy rates compared
with the transfers made without ultrasonography
In our study we found that the group with RIF was composed of poor prognosis patients who were older, overweight, had a longer infertility duration, an elevated FSH level, and needed to use more gonadotropins in COH.
Sperm motility and morphology were better in the RIF group compared to the non-RIF group and multiple pregnancy rates were lower in RIF patients. In such patients, the RIF probability must be taken into account and an appropriate treatment must be made individually.