Signal of the endometrium ready for implanation: genetic ...cme-utilities.com/mailshotcme/Material for Websites/OC/2019... · Data: 2,149 cells from 19 healthy ovum donors throughout

Signal of the endometrium ready

for implanation: genetic clinical

diagnosis

Xavier Santamaria MD; PhD.Director Asherman’s Project, iGenomix

Research Associate, Ob/Gyn Department VHIR

Ob/Gyn IVI Barcelona

Xavier Santamaria

Director of Asherman’s Project, Igenomix

Disclosure

ART remains inefficient

✓Globally, live birth rates in ART range between 25% and 30% per

initiated cycle

✓ The most fundamental reason why IVF treatments are not successful is

because transfer of good quality embryos or even euploid embryos

into the endometrial cavity does not lead to pregnancy.

Malizia B et al., N Engl J Med. 2009

Adamson et al., Fertil Steril. 2011

74 % of failed IVF cycles = failed implantation

IVF results, The Netherlands, 2010

92%

81%

27% (37% cum)

27% (37% cum)

Total 16,898 started cycles

48% ICSI

Cum = fresh+froozen ET

91% singleton pregnancies

The contribution of the embryonic and endometrial factor

Embryo Aneuploidies

Drosophila 0.01 %

Mouse 0.01 %

Human 20 – 100 %

Implantation Rate (IR)

Natural cycle 35 %

Euploid embryos 60 %

Rodents 95 %

Rabbits 96%

(Rubio et al. RCT Fertil Steril 2017)

The main difference between humans and rodents lies in

The endometrial/decidual control in human implantation

versus

The embryo control in rodent implantation (embryonic diapause)

Endometrial

Microbiota

Moreno et, al. AJOG 2016

Moreno et, al. AJOG 2018

Endometrial Receptivity

Diaz-Gimeno et, al. F&S 2011

Ruiz-Alonso et, al. F&S 2013

Garrido-Gomez et. al, HR 2014

Von Grothusen et. al, HR 2018

Wang W. et al. Nature Medicine.

2019 in press

Simon C. et al. HR 2019 in press

Decidualization Decidualization

Garrido-Gomez et. al, JCEM 2011

Garrido-Gomez et. al, Development 2017

Garrido-Gomez et. Al, PNAS 2017

Vilella et, al. Development 2015

Balaguer et, al. MHR 2018

Balaguer et, al. AJOG 2019

The Maternal Contribution

Materno-Embryonic Crosstalk

Endometrial

microbiota

Endometrial

receptivity

Decidualization

Materno-embryonic crosstalk

The Maternal Contribution

Endometrial receptivity

Plasma membrane transformation

Anatomical medicine: dating the endometrium

300 protocols reviewed

40 correlated with basal body temperature

13 were photographed

8 major histologic criteria were described

The most cited paper ever in Obst/Gyn.

RCTs: Murray et al., Fertil Steril 2004; Coutifaris, et al. Fertil Steril 2004

2,630 times cited

Endometrial thickness and pregnancy rates after IVF: a systematic review and meta-analysis

Kasiu et al., Hum Reprod Update, 2014

The use of EMT as a tool to decide on cycle cancellation, freezing of all embryos or

refraining from further IVF treatment seems not to be justified based on the current

meta-analysis

Endometrial Thickness (EMT) is not diagnostic of endometrial receptivity

Riesewijk et al., 2003 (HG-U133 2.0) WOI

Ponnapalam et al., 2004 (Home-made array) menstrual cycle

Talbi et al., 2005 (HG-U133 2.0) menstrual cycle

WOI

Molecular medicine: human endometrial transcriptome

Díaz-Gimeno et al., Fertil Steril 2011

Receptive

ERA classifies the molecular receptivity status of the endometrium

Post-ReceptivePre-Receptive

The symphony of syncronization

Progesterone

Epithelial

PR

P P+1 P+2 P+3 P+4 P+5 P+6 P+7 P+8 P+9

Personalized embryo transfer (pET) as a treatment for RIF of endometrial origen

P+5P+3 P+7

LH+7LH+5 LH+9

ETpET

How many lines of evidence lead to the conclusion

Essential protection against flawed ideas is triangulation.

This is the strategic use of multiple approaches to address one question.

Each approach has its own unrelated assumptions, strengths and weaknesses.

Munafo & Davey Nature 553, 399-401 (2018)

Single cell analysis from endometrial biopsy

Stromal

cells

Epithelial

cells

Single cell separation

Wash cells with

DMEM medium

Endometrial biopsy

Single-cell isolation

500 bp

Wanxin et al., bioRxiv online Jun. 19, 2018;

doi: http://dx.doi.org/10.1101/350538 Nature Medicine submitted.

Data: 2,149 cells from 19 healthy ovum donors throughout their natural menstrual cycle.

http://dx.doi.org/10.1101/350538

Endometrial Cell Types at Transcriptome Level

log2 (rpm+1)

log2

(FC)

4.5

7.5

Cellular component (FDR)

Biological process (FDR)113 + 6 single cells analyzed per donor:

• 48.23 % epithelial cells (2.19% ciliated and 46.04%

non-ciliated)

• 43.76% stromal fibroblasts,

• 1.44% endothelial,

• 5.91% lymphocytes

• 0.65% macrophages

Temporal Transcriptome Dynamics

mid-secearly-seclate-promenstrual early-pro late-sec

WOI

Un

cili

ate

d

ep

ith

elia

log2 (rpm+1)

Decidualization

mid-secearly-seclate-promenstrual early-pro late-sec

Str

om

al

fib

rob

last

s

CLINICAL WORK-CONNEGATIVE HYPOTHESYS

CLINICAL WORK-CON

Control Group (n=11)

LH+7

LH+2

LH+7

Day 3 – 9 of cycle

Treated Group (n=7)

LH+7

LH+2

Mifepristone

Von Grothusen et al., 2018

What if ET is performed in a Non-Receptive WOI diagnosed by ERA?

Clinical Outcome NR (52) R (205)

IR First attempt 13% (12/90) 45% (161/355)

IR Total attempts 10% (17/174) 41% (182/441)

PR First attempt 23% (12/52) 60% (123/205)

PR Total attempts 17% (17/100) 55% (140/253)

OPR First attempt 0% (0/12) 74% (91/123)

OPR Total attempts 0% (0/100) 74% (103/140)

Clinical efficiency Positive (52) Negative (205)

True 40 123

False 12 82

Sensitivity (TP/TP+FN) 0.33

Specificity (TN/TN+FP) 0.91

PPV (TP/TP+FP) 0.77

NPV (TN/TN+FN) 0.60

P-466 Ruiz-Alonso et al, Clinical efficiency of embryo transfer performed in receptive vs non-receptive endometrium

diagnosed by the endometrial receptivity array (ERA) (70th ASRM Annual Meeting, Honolulu, Hawaii. 2014)

CLINICAL WORK-PRO

Editorial, Expert Opinion

Case Series, Case Report

Case-Control Studies

Cohort Studies

RandomizedControlled Trial

Meta-Analysis

ERA Publications

2014 Clinical Management of Endometrial Receptivity Semin Reprod Med. 32(5):410-4

2014Timing the window of implantation by nucleolar channel system prevalence matches the accuracy of the

endometrial receptivity arrayFertility and Sterility. 102(5):1477-81

2015 Human Endometrial Transcriptomics: Implications for Embryonic ImplantationCold Spring Harb Perspect Med.

5(7):a022996

2015 Understanding and improving endometrial receptivityCurrent Opinion in Obstetrics &

Gynecology. 27(3):187-92

2015 Is endometrial receptivity transcriptomics affected in women with endometriosis? A pilot studyReproductive BioMedicine Online.

31(5):647-54

2016 Diagnosis of endometrial-factor infertility: current approaches and new avenues for research Geburtshilfe Frauenheilkd.76(6): 699-703

2017Does an increased body mass index affect endometrial gene expression patterns in infertile patients? A functional

genomics analysisFertility and Sterility.107(3):740-748.e2

2017 Endometrial function: facts, urban legends, and an eye to the future Fertility and Sterility. 108(1):4-8

2017Implantation failure of endometrial origin: it is not pathology, but our failure to synchronize the developing embryo

with a receptive endometriumFertility and Sterility. 108(1):15-18

2017 Meta-signature of human endometrial receptivity: a meta-analysis and validation study of transcriptomic biomarkers Scientific Reports. 7(1):10077

2017Window of implantation transcriptomic stratification reveals different endometrial subsignatures associated with live

birth and biochemical pregnancyFertility and Sterility. 108(4):703-710.e3

2018 Implantation failure of endometrial origin: what is new?Current Opinion in Obstetrics and

Gynecology. PMID: 29889670

2018 Inter-cycle consistency versus test compliance in endometrial receptivity analysis testJournal of Assisted Reproduction and

Genetics. 2018 May 26. PMID: 29804174.

YEAR TITLE JOURNAL

Ruiz-Alonso, et al. Fertil Steril 2013

Ruiz-Alonso, et al. Fertil Steril 2013

Independent retrospective studies

2015Endometrial receptivity array: Clinical

application

J Hum Reprod Sci. 2015;

8(3):121-9.

2017

Efficacy of the endometrial receptivity

array for repeated implantation failure in

Japan: A retrospective, two-centers study.

Reprod Med Biol.

2018

The role of the endometrial receptivity

array (ERA) in patients who have failed

euploid embryo transfers

J Assist Reprod Genet

2018; 35(4): 683-92.

YEAR TITLE JOURNAL

ERA RCT – Study protocol overview

Population: IVF patients at their first appointment undergoing blastocyst transfer

Primary objectives Secondary objectives

LB and cumulative LB rates at 1-year follow-up

(pET versus FET and pET versus ET)

Implantation and pregnancy rates, biochemical and

clinical miscarriages, ectopic pregnancy, obstetrical,

neonatal outcomes and cost-effectiveness.

Day 5/6

pET FET ET

Transfer

Thawed embryos

Cryopreserved embryos

HRT

ERA

01954758

(1st Release: Sep 26th, 2013)

(Last update: Nov 4th, 2018)

First IRB/EC approval July 2, 2013

EC FWA# 00027749

Last IRB/EC approval April 28, 2016

FPFI October 2013

Last LB (LPLV) September 2018

Study length 5 years

Recruitment length 4 years

https://clinicaltrials.gov/ct2/show/NCT01954758?term=01954758&rank=1

ERA RCT Study Sites

16 Active sites worldwide

Participant sites

Enrolled patients (n)

N EXPECTED 546

IRB/EC APPROVED SITES 16

N RECRUITED 569

(339)

(17)

(39)

(7)

(116)

(14)

(20)

(11)(6)

Inclusion Criteria

1. Patients undergoing IVF at the first appointment

2. Age ≤ 37 years

3. BMI: 18.5 to 30

4. Normal ovarian reserve (AFC > 8; FSH < 8)

5. The stimulation protocol was decided by the doctor

6. Blastocyst transfer (day 5 or 6)

Exclusion Criteria

1. Recurrent miscarriage

2. Severe male factor (< 2 million/ml)

3. Implantation failure (>3 failed cycles)

4. Any pathology affecting the endometrial

cavity and hydrosalpinx must be previously

operated

Post-Randomization Exclusion Criteria

1. P4 level > 1,5 ng/ml at the day of hCG administration in all groups

2. Absence of blastocysts for embryo transfer

3. Risk of OHSS in the fresh ET group

Note. PGT-A was NOT an inclusion criteria NEITHER an exclusion criteria

ERA RCT Selection criteria

CONSORT Flow Diagram – ERA RCT

569 assessed for eligibility

458 randomized

Total 111 declined randomization51 did not meet selection criteria 43 declined to participate 8 double randomization by mistake6 site exclusion due to data inconsistency and submitted out of deadline 3 inclusion error

154 allocated to frozen ET

Enrollment

Allo

cati

on

Follo

w u

pA

nal

ysis

92 followed up after the first ET

148 ITT analysis92 per protocol analysis

137 proceeded with ET

6 Lost FU

92 proceeded with FET

45 no protocol compliance 3 embryo day 3 ET 1 embryo day 4 ET 22 had Fresh ET 5 had pET13 high P4 in COS1 ovum donation

148 allocated to personalized ET




81 proceeded with PET

51 no protocol compliance 1 embryo day 3 ET 5 embryo day 4 ET 10 had Fresh ET 7 had Frozen ET 18 High P4 in COS7 no pET2 other treatment (INVO) 1 protocol deviation

1 voluntary termination of pregnancy

156 allocated to fresh ET




95 proceeded with day ET

43 no protocol compliance2 embryo day 2 ET 8 embryo day 3 ET 1 embryo day 4 ET and high P4 in COS6 had Frozen ET13 had Frozen ET due to OHSS risk 1 had pET (n=1)12 high P4 in COS


141 Followed up

7 Lost FU 11 Lost FU

145 Followed up 9 did not received ET

7 no blastocyst for ET2 spontaneous pregnancy

7 did not received ET 1 no ET data 3 no blastocyst for ET2 cancelled due to OHSS risk 1 spontaneous pregnancy

148 Followed up

11 did not received ET 2 no ET data6 no blastocyst for ET 3 spontaneous pregnancy


458 randomized

154 allocated to frozen ETAllo

cati

on

Follo

w

up

An

alys

is

6 Lost FU

148 allocated to personalized ET 156 allocated to fresh ET

7 Lost FU 11 Lost FU

141 ITT analysis 148 ITT analysis 145 ITT analysis

Follo

w u

pA

nal

ysis 92 PP analysis


92 proceeded with FET

45 no protocol compliance 3 embryo day 3 ET 1 embryo day 4 ET 22 had Fresh ET 5 had pET13 high P4 in COS1 ovum donation

80 PP analysis


81 proceeded with PET

51 no protocol compliance 1 embryo day 3 ET 5 embryo day 4 ET 10 had Fresh ET 7 had Frozen ET 18 High P4 in COS7 no pET2 other treatment (INVO) 1 protocol deviation


94 PP analysis


95 proceeded with day ET

43 no protocol compliance2 embryo day 2 ET 8 embryo day 3 ET 1 embryo day 4 ET and high P4 in COS6 had Frozen ET13 had Frozen ET due to OHSS risk 1 had pET (n=1)12 high P4 in COS


141 ITT analysis 145 ITT analysis9 did not received ET

7 no blastocyst for ET2 spontaneous pregnancy

7 did not received ET 1 no ET data 3 no blastocyst for ET2 cancelled due to OHSS risk 1 spontaneous pregnancy

148 ITT analysis11 did not received ET

2 no ET data6 no blastocyst for ET 3 spontaneous pregnancy


PersonalizedEmbryoTransfer. pET(n = 148) FrozenEmbryoTransfer. FET (n = 154) FreshEmbryoTransfer. ET (n = 156)

Age (y) 33 ± 3.1 32.8 ± 3.4 32.7 ± 3.3Body-mass index§ 22.8 ± 2.9 22.9 ± 2.9 22.6 ± 2.8Ethnicity (%)

Caucasian 122 (82.4) 127 (82.5) 129 (82.7)Asian 12 (8.1) 12 (7.8) 11 (7.1)Latin American 13 (8.8) 11 (7.1) 13 (8.3)African 0 (0.0) 4 (2.6) 1 (0.6)Other or unknow 1 (0.6) 0 (0.0) 2 (1.2)

Current smoker 15 (10.1) 12 (7.8) 15 (9.6)Fertility history

Duration of infertility (y) 3.1 ± 1.9 3.2 ± 2.1 2.9 ± 2.2No. of previous IVF failed

0 109 (73.6) 104 (67.5) 112 (71.8) 1 20 (13.5) 23 (14.9) 22 (14.1)2 10 (6.7) 10 (6.5) 12 (7.7)3 6 (4.0) 11 (7.1) 6 (3.8)

Previous Deliveries 1 11 (7.4) 16 (10.3) 17 (10.9)≥2 3 (2.0) 4 (2.6) 3 (1.9)

Spontaneous clinical miscarriages1 23 (15.5) 26 (16.9) 24 (15.4)≥2 6 (4.0) 3 (1.9) 0 (0.0)

Voluntary abortions 3 (2.0) 9 (5.8) 8 (5.1)

Previous curettages (1 or 2) 12 (8.1) 11 (7.1) 10 (6.4)

Ectopic pregnancies 8 (5.4) 3 (1.9) 4 (2.6)

IVF indication (%)

Male factor 65 (43.9) 78 (50.6) 50 (32.1)

Tubal factor 20 (13.5) 31 (20.1) 33 (21.1)

PCOS 27 (18.2) 20 (12.9) 14 (8.9)

Ovarian disorders 4 (2.7) 5 (3.2) 7 (4.5)

Endometriosis 21 (14.2) 9 (5.8) 13 (8.3)

Unexplained 33 (22.3) 33 (21.4) 47 (30.1)

Other or unknown‡ 2 (1.3) 4 (2.6) 10 (6.4)

Laboratory tests

FSH (mU/mL) 5.9 ± 1.9a 6.6 ± 2.1 6.9 ± 2.0b

AMH (ng/nL) 4.4 ± 3.6 3.7 ± 2.7 3.5 ± 2.9

Demographic and clinical characteristics of the patients at baseline

PersonalizedEmbryo Transfer. pET (n = 141) Frozen Embryo Transfer. FET (n = 148) FreshEmbryo Transfer. ET (n = 145)

AFC 14.8 ± 6.3 14.9 ± 6.6 13.1 ± 5.9Antagonist protocol 124 (87.9) 120 (81.1) 122 (84.1)Agonist protocol 10 (7.1) 13 (8.8) 12 (8.3)

Total dose of FSH administered (IU) 1696.9 ± 687.8 1540.2 ± 635.2 1666.1 ± 669.8Total dose of hMG administered (IU) 1167.03 ± 936 1202.3 ± 987 1165.1 ± 1042.5P level at the day of ovulation induction 1.02 ± 0.7 0.93 ± 0.6 0.92 ± 0.8Ovulation induction

hCG 62 (44.0)a 57 (38.5)a 110 (75.9)b

Agonist 62 (44.0)a 67 (45.3)a 15 (10.3)b

Double triggering 7 (5.0) 7 (4.7) 7 (4.8)Oocytes retrieved 12.4 ± 7.6 11.6 ± 6.0 10.5 ± 6.6Fertilization technique

ICSI 106 (75.2) 114 (77.0) 111 (76.6)IVF 5 (3.5) 6 (4.1) 9 (6.2)IVF/ICSI 21 (14.9) 13 (8.8) 21 (14.5)

Fertilization rate 1244/1633 (76.2) 1197/1531 (78.2) 1067/1379 (77.4)Embryo Stage

Cleavage stage 1/181 (0.6) 0 (0.0)a 7/211 (3.3)b

Morula 2/181 (1.1) 1/208 (0.5) 1/211 (0.5)Early Blastocyst 12/181 (6.6) 11/208 (5.3) 5/211 (2.4)Cavitated blastocyst 40/181 (22.1) 47/208 (22.6) 48/211 (22.7)Expanded Blastocyst 93/181 (51.4) 100/208 (48.1) 109/211 (51.7)Hatching Blastocyst 33/181 (18.2) 49/208 (23.6) 41/211 (19.4)

Blastocyst development rate 648/1248 (51.9) 636/1239 (51.3) 561/1093 (51.3)Day of embryo development at transfer

2 0 (0.0) 0 (0.0) 2 (1.4)3 10 (7.1) 4 (2.7) 10 (6.9)4 7 (5.0)a 4 (2.7) 0 (0.0)b

5 98 (69.5)a 112 (75.7) 119 (82.1)b

6 16 (11.3) 17 (11.5)a 6 (4.1)b

Embryo QualityICM"A" grade 48/149 (32.2) 70/183 (38.3) 56/183 (30.6)"B" grade 84/149 (56.4) 92/183 (50.3) 110/183 (60.1)"C" grade 17/149 (11.4) 21/183 (11.5) 17/183 (9.3)

TE"A" grade 36/149 (24.2) 56/183 (30.6) 46/183 (25.1)"B" grade 85/149 (57) 95/183 (51.9) 96/183 (52.5)"C" grade 28/149 (18.8) 32/183 (17.5) 40/183 (21.9)

PGT-A cases 6 (4.3) 4 (2.7) 3 (2.1)Number of transferred embryos 1.52 ± 0.5 1.61 ± 0.5 1.63 ± 0.5Thawed HRT embryo transfer data

No. of days of E2 15.5 ± 3.8a 16.6 ± 3.8b NAEndogenous P levels¶ 0.2 (0.03-1.4) 0.29 (0.05-11.03) NAHours exogeneous P admin. 120 ± 14.4 117.8 ± 9.7 NAHours exogeneous P admin. (range) 65.2-163.4 (98.2) 66.4-151.2 (84.8) NATime between COS and embryo transfer (months) 3.2 ± 2.4a 2.1 ± 1.4b NA

Cycle characteristics and embryological data. ITT analysis

pET (n = 141) FET (n = 148) ET (n = 145)pET vs FET pET vs ET

Relative risk (95% CI) P-value Relative risk (95% CI) P-value

No. of transfers 132 137 138

Pregnancy rate 83 (58.9) 73 (49.3) 84 (57.9) 1.22 (0.96-1.56) 0.12 1.02 (0.80-1.29) 0.9

Implantation rate 88/201 (43.8) 80/220 (36.4) 97/225 (43.1) 1.17 (0.96-1.43) 0.14 1.01 (0.83-1.24) 0.92

LB rate 57 (40.4) 51 (34.5) 64 (44.1) 1.14 (0.90-1.44) 0.33 0.92 ( 0.73-1.18) 0.55

Singleton 49/57 (86) 40/51 (78.4) 45/64 (70.3) 1.31 (0.75-2.29) 0.32 1.76 (0.95-3.25) 0.049

Multiple (all twins) 8/57 (14) 11/51 (21.6) 19/64 (29.7) 0.76 (0.44-1.34) 0.32 0.57 (0.31-1.05) 0.049

Clinical miscarriages 17/83 (20.5) 11/73 (15.1) 5/84 (5.9) 1.18 (0.84-1.66) 0.41 1.70 (1.27-2.27) 0.006

Biochemical pregnancies 7/83 (8.4) 9/73 (12.3) 11/84 (13.1) 0.81 (0.45-1.43) 0.44 0.76 (0.42-1.39) 0.46

Ectopic pregnancies 1/83 (1.2) 1/73 (1.4) 1/84 (1.2) 0.93 (0.24-3.79) 1 1 (0.25-4.06) 1

No. of patients with surplus embryo

transfers57 (40.4) 57(38.5) 42 (28.9) 1.04 (0.82-1.32) 0.81 1.28 (1.02-1.62) 0.047

Total No. of surplus cycles and transfers 150 130 110

Cumulative No. of transfers 282 267 248

No. of pregnancies from surplus embryo ET 49 45 33

Cumulative pregnancy rate 132/141 (93.6)a 118/148

(79.7)b

117/145

(80.7)b 2.29 (1.27-4.11) 0.0005 2.18 (1.22-3.89) 0.0013

Cumulative LB rate 88/141 (62.4) 82/148 (55.4) 85/145 (58.6) 1.16 (0.91-1.49) 0.23 1.08 (0.85-1.39) 0.55

Singleton 75/88 (85.2) 67/82 (81.7) 58/85 (68.2) 1.14 (0.74-1.74) 0.54 1.73 (1.08-2.78) 0.011

Multiple (all twins) 13/88 (14.8) 15/82 (18.3) 27/85 (31.8) 0.88 (0.57-1.35) 0.54 0.58 (0.36-0.92) 0.011

Cumulative clinical miscarriages 24/132 (18.2) 17/118 (14.4) 5/117 (4.3) 1.13 (0.85-1.51) 0.49 1.69 (1.36-2.09) 0.0006

Cumulative biochemical pregnancies 19/132 (14.4) 16/118 (13.6) 23/117 (19.7) 1.03 (0.74-1.44) 1 0.83 (0.58-1.18) 0.31

Cumulative ectopic pregnancies 1/132 (0.8) 1/118 (0.8) 1/117 (0.9) 0.95 (0.24-3.81) 1 0.94 (0.23-3.79) 1

Transfers per patient 2.63 ± 1.14 2.28 ± 0.70 2.62 ± 0.73 0.35 (-0.4-0.4) 0.1 0.01 (-0.43-0.45) 1

Reproductive outcomes at the first embryo transfer and cumulative during 1-year follow-up*.

ITT analysis

Cumulative Pregnancy Rate

pET (n = 141) FET (n = 148) ET (n = 145)

pET vs FET pET vs ET


132/141 (93.6 %)a 118/148 (79.7%)b 117/145 (80.7%)b 2.29 (1.27-4.11) 0.0005 2.18 (1.22-3.89) 0.0013

pET (n = 80) FET (n = 92) ET (n = 94)pET vs FET pET vs ET


Pregnancy rate 58 (72.5) 50 (54.3) 55 (58.5) 1.56 (1.07-2.29) 0.01 1.42 (0.98-2.08) 0.057

Implantation rate 63/110 (57.3) 60/139 (43.2) 58/150 (38.6) 1.37 (1.03-1.82) 0.03 1.54 (1.15-2.05) 0.004

LB rate 45 (56.2) 39 (42.4) 43 (45.7) 1.35 (0.97-1.86) 0.09 1.26 (0.91-1.74) 0.17

Singleton 40/45 (88.9) 30/39 (76.9) 33/43 (76.7) 1.60 (0.77-3.33) 0.16 1.64 (0.78-3.46) 0.16


Clinical miscarriages 9/58 (15.2) 7/50 (14) 3/55 (5.4) 1.06 (0.66-1.69) 1 1.55 (1.05-2.27) 0.13

Biochemical pregnancies 4/58 (6.9) 4/50 (8) 8/55 (14.5) 0.93 (0.45-1.89) 1 0.62 (0.27-1.42) 0.23

Ectopic pregnancies 0 (0.0) 0 (0.0) 1 (1.8)

No. of patients with surplus embryo

transfers19 (23.7) 16 (17.4) 4 (4.2)

Total No. of surplus cycles and transfers 39 18 10

Cumulative No. of transfers 119 110 104

No. of pregnancies from surplus embryo

transfers18 15 4

Cumulative pregnancy rate 76/80 (95) 65/92 (70.6) 59/94 (62.8) 4.18 (1.65-10.56) 0.0001 5.49 (2.14-14.06) 0.0001

Cumulative LB rate 57 (71.2) 51 (55.4) 46 (48.9) 1.47 (1.01-2.13) 0.04 1.71 (1.17-2.49) 0.003

Singleton 51/57 (89.5) 41/51 (80.4) 34/46 (73.9) 1.48 (0.76-2.86) 0.28 1.80 (0.92-3.54) 0.066


Cumulative clinical miscarriages 10/76 (13.2) 8/65 (12.3) 3/59 (5.1) 1.03 (0.66-1.61) 1 1.42 (1.01-1.99) 0.15

Cumulative biochemical pregnancies 9/76 (11.8) 6/65 (9.2) 9/59 (15.3) 1.13 (0.72-1.76) 0.78 0.87 (0.54-1.42) 0.62

Cumulative ectopic pregnancies 0 (0.0) 0 (0.0) 1/59 (1.7)

Transfers per patient 3.05 ± 1.61 2.13 ± 0.34 3.5 ± 1.29 0.92 (-0.11-1.97) 0.09 -0.45 (-2.13-1.24) 1

Reproductive outcomes at the first embryo transfer and cumulative during 1-year follow-

up*. Per protocol analysis

pET (n = 80) FET (n = 92) ET (n = 94)

pET vs FET pET vs ET

Relative risk

(95% CI) P-value

Relative risk

(95% CI) P-value

Pregnancy rate 58 (72.5%) 50 (54.3%) 55 (58.5%) 1.56 (1.07-2.29) 0.01 1.42 (0.98-2.08) 0.057

Implantation rate 63/110 (57.3%) 60/139 (43.2%) 58/150 (38.6%) 1.37 (1.03-1.82) 0.03 1.54 (1.15-2.05) 0.004

LB rate 45 (56.2%) 39 (42.4%) 43 (45.7%) 1.35 (0.97-1.86) 0.09 1.26 (0.91-1.74) 0.17

Cumulative

pregnancy rate76/80 (95%) 65/92 (70.6%) 59/94 (62.8%) 4.18 (1.65-10.56) 0.0001 5.49 (2.14-14.06) 0.0001

Cumulative LB

rate57 (71.2%) 51 (55.4%) 46 (48.9%) 1.47 (1.01-2.13) 0.04 1.71 (1.17-2.49) 0.003

Personalized-Embryo Transfer. pET (n = 80)

Frozen-Embryo Transfer. FET (n = 92) Fresh-Embryo Transfer. ET (n = 94)

No. of outcomes No. of outcomes No. of outcomes

Ovarian hyperstimulation 80 0 (0.0) 92 0 (0.0) 94 1 (1.1)Obstetrical outcomes 45 39 43

Gestational diabetes 2 (4.4) 1 (2.6) 1 (2.3)HBP 1 (2.2) 0 (0.0) 0 (0.0)Placenta previa 1 (2.2) 1 (2.6) 0 (0.0)Retrocorial hematoma 0 (0.0) 1 (2.6) 1 (2.3)Abruption 1 (2.2) 0 (0.0) 0 (0.0)Vasa previa 1 (2.2) 0 (0.0) 0 (0.0)Still birth 1 (2.2) 1 (2.6) 0 (0.0)

Type of delivery 40 35 43C-Section 10 (25.0) 14 (40.0) 15 (34.9)Vaginal 30 (75.0) 21 (60.0) 28 (65.1)

Neonatal outcomes‡ 40 35 43Neonatal mortality 0 (0.0) 1 (2.9) 0 (0.0)Gestational age

(weeks)38 38.03 ± 3.1 34 38.03 ± 2.9 42 38.33 ± 1.6

Preterm birth <37 weeks

38 5 (13.2) 34 6 (17.6) 42 4 (9.5)

Birth weight (g) 23 3170.6 ± 646.9 302868.5 ±

629.134 2912.6 ± 573.6

Birth weight in singletons

17 3484.4 ± 321.6 14 3362.5 ± 402 223210.68 ±

375.6

Birth weight in twins 6 2281.7 ± 476.7 162436.2 ±

444.912 2366.2 ± 463.2

Birth weight <2500 g 23 4 (17.4) 30 10 (33.3) 34 6 (17.6)

Obstetrical, delivery and neonatal outcomes. Per protocol analysis

Personalized-Embryo Transfer pET (n = 80)

Frozen-EmbryoTransfer FET (n = 92)

Fresh-EmbryoTransfer ET (n = 94)

No. of deliveries with at least 1 LB at the first attempt

45 39 43

EU USA EU USA EU USA

IVF lab cost € 5.190 $ 11.825 € 5.190 $ 11.825 € 5.590 $ 12.325

Drug cost € 1.700 $ 5.500 € 1.600 $ 4.700 € 1.580 $ 4.500

Vitrification cost € 1.100 $ 1.375 € 1.100 $ 1.375 - -

Additional cost in pET and FET € 2.050 $ 3.500 € 2.050 $ 3.500 - -

Cost of ERA € 710 $ 795 - - - -

Mock cycle € 250 $ 1.000 - - - -

Total cost per embryo transfer

€ 11.000 $ 23.995 € 9.940 $ 21.400 € 7.170 $ 16.825

Estimated cost of a delivery with at least 1 LB at the first attempt

€ 19.555 $ 42.658 € 23.448 $ 50.482 € 15.674 $ 36.780

Cost-effectiveness estimation per baby at home at the first attempt

Personalized-Embryo Transfer pET (n = 80)

Frozen-EmbryoTransfer pET (n = 92)

Fresh-EmbryoTransfer pET (n = 80)

EU USA EU USA EU USA

Estimated cost of a delivery with at least 1 LB at the first attempt

€ 19.555 $ 42.658 € 23.448 $ 50.482 € 15.674 $ 36.780

ERA RCT Take-home messages

✓ By ITT analysis,

Cumulative PR was significantly in the pET group (93.6%) vs FET (79.7%) and ET (80.7%).

✓ By PP analysis,

LB 14 pp and 11 pp versus FET and ET that was non statistically significant.

Statistically significant improvement in:

Cumulative LBR 16 pp and 22.1 pp versus FET and ET.

PR 18.2 pp and 14 pp versus FET and ET.

IR 14 pp and 18.4 pp versus FET and ET.

Cumulative PR 24.4 pp and 32.1 pp versus FET and ET.

✓ Similar clinical outcome between FET and ET.

✓ Obstetrical, delivery and neonatal outcomes were not different.

Simon C et al., Human Reprod submitted

Limitations, reasons for caution

✓ The main limitation of our study is the unexpected added 20% patient drop-

out rate versus 30% initially planned (16 study sites in 3 different continents).

✓ The study was powered to detect statistical differences for a 15-

percentage points increase in the primary outcomes in the pET group

versus FET or ET.

✓ This is the first RCT to provide proof-of-principle evidence for the potential of

using a personalized diagnosis of the endometrial factor in the work-up of

the infertile couple at the first appointment

Future Directions

1978 2010

IVF 1.0

ChromosomalEmbryo Factor1

5%

IVF 2.0

LIV

E B

IRTH

RA

TES %

5

15

25

35

45

55

65

10

20

30

40

50

60

Endometrial Factor1

5%

NCT03530254 (May 21, 2018)NCT3558399 (June 15, 2018)

Conclusions

✓ Precision medicine supported by contrasted basic researchtogether with clinical translation in an evidence-based medicineapproach should guide the improvement of our field

✓ Black box can be unravelled: Endometrial receptivity andmicrobiome are now actionable functions that can improve ourclinical practice

✓Clinical outcome of the personalized endometrial factor approachincreses cumulative PR per ITT and cumulative LBR and PR and PRand IR per protocol analysis

Research DirectorFelipe Vilella, PhD

Research ManagerInmaculada Moreno, PhD

ResearchersTamara Garrido, PhD

Aymara Mas, PhD

Medical ManagerDiana Valbuena, MD, PhD

Ruth Lathi, Stanford University

ERA Team

FINANCIAL SUPPORT

COLLABORATORS

David Blesa

Carlos Gómez

Diana Valbuena

Steve Quake LABSteve Quake

Wanxin Wang

Wenying Pan

Documents

Signal of the endometrium ready for implanation: genetic ...cme-utilities.com/mailshotcme/Material for Websites/OC/2019... · Data: 2,149 cells from 19 healthy ovum donors throughout