In this webinar, Dr Esther Marbán, Gynaecologist & Fertility Specialist at Clinica Tambre, Madrid, Spain talked about the endometrial microbiome, receptivity and its immunological aspects.
Dr Marbán defines the endometrium as the innermost layer of the uterus, which is where the embryo implantation and the fetus development take place. The endometrium changes monthly due to the ovarian hormones. Estrogens, which are produced in the ovaries, are responsible for the production of the lining thickening to prepare for a potential pregnancy. It is the same case with progesterone. Progesterone prepares the endometrium for the pregnancy, supplying the lining and stimulating the glands to grow to nourish the early embryo.
As Marbán mentioned, the endometrium is the place where the embryo implants, meaning that having a good endometrium is connected to higher pregnancy rates. We also need a good thickness and triple line aspect to achieve better chances of implantation. These aspects can be achieved in different ways.
Dr Marbán explains that when we do an IVF cycle and the ovaries are stimulated, these produce estrogen that affects the endometrial lining, making it thicker. Besides, we can also use a natural cycle in which we do not need to use any specific medication in the first part of the cycle to thicken the endometrium for the eventual implantation. This is the case of frozen embryo transfers, when a natural cycle is more commonly used, to have the endometrium in the best conditions.
Another common scenario for frozen embryo transfer occurs when patients require or prefer to use estradiol or progesterone to prepare their endometrium.
There is also a small and specific group of patients who may need other therapies, such as gonadotropins, aspirin, or even other treatments trying to thicken the endometrium. In general, most patients do not experience significant issues with endometrial preparation, and a natural cycle or standard treatment is usually sufficient.
The window of implantation is known as the period of time when the endometrium has the best conditions for embryo implantation.
Once we find that moment, we talk about a receptive endometrium. This period is short, and it depends on the effect of estrogen and progesterone in the uterine lining and varies between women.
Dr Marbán says that typically the window of implantation is placed around 5 days after adding the progesterone in many patients, and around dates 19 and 21 in a natural cycle. However, not all patients have that window of implantation in the same place. It is known that around 30% of patients may have the window of implantation displaced.
Then she mentions some tests that are useful to test this kind of issue, and the most known is called ERA. It stands for endometrial receptivity analysis. ERA tests 248 genes involved in implantation, and an endometrial biopsy taken in a mock cycle is necessary. No kind of surgery is needed. It can be taken in the consultation.
Normally, we prepare the endometrium with a natural cycle, or even with medications such as estrogen and progesterone, and we try to do the same that we will be doing in the eventual next embryo transfer. At that moment, a small sample of the endometrium is sampled in the consultation and that window of implantation is tested. Once the report is ready, we can personalise the eventual embryo transfer.
As it was previously mentioned, some patients may have a different gene expression that may affect the window of implantation and the endometrial receptivity. Consequently, this test may help personalise the embryo-transfer moment. For instance, if we find that one patient requires more or fewer hours of progesterone, it can be done for the next embryo transfer to increase the implantation rate.
Dr Marbán defines the endometrial microbiome as the totality of microorganisms in the endometrium. A normal endometrial microbiome is dominated by lactobacilli species, meaning it needs to have a quite high percentage of lactobacilli species inside it. She also adds that pathogenic deviations in the dominant microbiome may play a role in infertility. An abnormal endometrial microbiome has been associated with implantation failure, pregnancy loss and adverse surgical outcomes.
By looking at the graphic above, in the first column, we can see how the proportion of lactobacilli species (blue) is dominant, which means that that group of patients had a good pregnancy. If we compare the first column with the ones that did not have a good outcome, patients who did not have these dominant lactobacilli species in the endometrium, we can observe that the outcomes during the pregnancy were not so good. So, the second column shows the miscarriage and implantation failure in the end. This graphic illustrates the importance of having this type of species present in our endometrium.
Dr Marbán explains some tests may help patients with that kind of issue. ALICE and EMMA are the most known ones. ALICE detects bacteria causing chronic endometritis, which is a long-term inflammation of the endometrial tissue, caused normally by an infection, and EMMA tests the endometrial microbiome. The idea is that both tests may provide very useful information on the endometrial bacteria, which may be of higher importance for our medical practice. Then, in the case an infection or a microbiome alteration is confirmed, an accurate treatment will be recommended by the professional.
As stated before, the professional will take that small sample of the endometrium to test all those issues (ALICE, EMMA, and ERA) to have a good approach on what is going on the endometrium. If any alteration in the microbiome is found in the patient, the professional will normally recommend using some antibiotics for one week or 10 days. It will depend on the bacteria causing the problem. Some vaginal probiotics are also recommended to try to have those lactobacilli back in the endometrium, and, in the end, have a better chance of implantation of the next embryos.
Dr Marbán adds that it is quite common to find patients in consultations that have tried several times. We normally recommend doing a complete examination of the uterus to have the best information about it, and to be able to add any specific treatments in case it is needed.
Research suggests the immune system cells, such as natural killer cells and lymphocytes, may play a role in the reproduction ability and maintenance of early pregnancy. So, the NK cells and endometrial testing, with an endometrial luteal phase biopsy, may help identify women at risk of implantation failure or recurrent miscarriage, who may benefit from a specific treatment. According to Dr Marbán’s words, immune testing and treatment is not required for most patients. This is something very important to know and to clarify because most patients won’t need to have that test done, and they won’t need any specific treatment. Then, that test could be requested in patients with failure of implantation or regular miscarriages where no other causes have been identified, and when embryonic factors have been previously all out.
Dr Marbán emphasises more research is needed to prove a definite link between alterations in the NK cells and adverse reproductive outcomes, as well as to confirm what treatment would be of benefit. In the end, professionals normally prefer to concentrate on treatments and the tests that have proved their efficacy because immunology helps us in general, but these tests are really specific, and they have to be requested in a very specific group of patients.
Dr Marbrán emphasises the crucial role the endometrium plays in fertility treatments.
A healthy endometrium can significantly improve the implantation rate.
In addition to the standard examination with a vaginal ultrasound, various endometrial tests can provide a deeper understanding of the endometrium’s function and receptivity. Our primary goal is to enhance reproductive outcomes.
The biopsy itself is not very painful. Of course, we need to take that small biopsy, and we use a very thin catheter to go inside the uterus, which is a bit thicker than the one that we use to do the embryo transfer, and normally it’s not painful. So, I would say that it’s not very nice to feel that, but it’s not painful itself. It’s just a quite short procedure. It lasts maybe 10 minutes, but of course, it always depends on how difficult it is to go with the catheter inside the cervix and the cavity. Of course, it depends on each patient.
Well, of course, it depends on other factors. It’s not just having an ERA test done. It’s supposed that it may increase the implantation rate. Of course, we need to clarify that we are always talking about other issues like, for example, testing the embryos, doing the PGT-A on the embryos, and being sure that the embryos are brought up healthy. So, that kind of embryo could increase the implantation rate by approximately 20% of approximately. Of course, it always depends on other factors, but we know that it’s important to personalise the embryo transfer. As we mentioned, around 50% of patients could have that window of implantation in a different place when it should be. So, in the end, we can have that information.
Regarding how long the ERA test is valid for, it is normally valid for around two years, but, of course, it depends on the conditions of the patients. So, normally, if the ERA test is fine, it doesn’t need to be repeated. So, when the ERA test says the endometrium is post-receptive, it means that the window of implantation has gone. We know we need to do another mock cycle and repeat the endometrial biopsy, some hours before we took the first one, to try to clarify exactly when the wind of implantation is. When the endometrium is receptive or even pre-receptive, we know that we need to do the embryo transfer at a very specific moment, but when the wind of implantation has already passed, it’s impossible to know how many fewer hours of progesterone that patient may need, and that’s the reason we need to repeat the ERA test, but, normally, it’s not needed like I would say that more than 80% of samples are fine and don’t need to be repeated.
You don’t. So, if you have regular cycles, you don’t need to add any specific medication, and the laboratory just recommends taking the sample between days number 15 and 25 of your cycle. So, if the patient has regular cycles, it’s quite easy to know exactly when we need to take the biopsy of the endometrium. It’s not necessary to use a specific medication unless the patient is not menstruating, I mean, if the patient is in amenorrhoeal, of course, we need to add estrogen and progesterone to make that endometrium thicker. Otherwise, it’s not needed. So, just calculating when the moment for the endometrium is, and we just need to take that sample at that moment, and it could be more than enough
It’s almost in a neutral phase, between days 15 and 25 of the cycle. So, it’s just a matter of counting when the menstruation starts and counting those days to calculate when would be a good moment for the ALICE and EMMA tests.
Well, I guess that refers to all the other bacteria. So, the test is always performed in the way that we know exactly the proportion of lactobacilli that the patient has and the recommendation regarding the proportion of the lactobacilli the laboratory tells us. If it’s enough, obviously, the patient needs to use some probiotics, trying to have like a higher proportion of lactobacilli species inside the uterus, and also, the other test which is performed to test the other bacteria, the pathological bacteria that may also be inside the endometrium, and they specify what kind of bacteria the patient has, and also the recommended antibiotic therapy that the patient should use. So, we have all the information, and we have a complete report with all the important information for us.
It’s like one of the most common bacteria that we normally find in that sample is the Gardnerella bacteria, which is normally in our vagina, and it’s quite common to find it also in the endometrium.
Normally, it’s recommended, if we don’t find the dominant bacteria, which is not the lactobacillus, normally, it’s recommended to use some vaginal probiotics. Normally, they just need to be used for around 10 days, so it’s like normally enough time to make that endometrium microbiome change. In case we need to use any specific treatment or any specific antibiotic, normally, it is used for between 7 and 10 days, depending on the infection and also on the bacteria that is affecting the endometrium. But I would say that normally, between two weeks and a maximum of 3 weeks, it could be time enough to make that endometrium mainly in a different condition and, of course, be improved for the next embryo transfer.
Exactly. It’s also highly recommended to take another biopsy to confirm that the infection has gone and that the population of the lactobacillus is the one that we need. So, normally after doing that treatment we always recommend our patients do another endometrial biopsy, so that we can confirm that the infection has been treated and has been solved, and also that the lactobacilli species is increasing.
Well, I don’t know how to do it because it’s part of the immune system. It’s kind of a controversy regarding NK cells and immunology in general, but as far as I know, there are no natural remedies to try to change that kind of cell.
Of course, we may talk about the cells in the blood and cells in the uterus. But the tests that are performed on the uterus just test the uterine NK cells, so you need to have those NK cells tested in general, you should also perform a blood test to know the exact level of those cells. But we were talking about just the endometrial test.
It all will depend on the immunologist’s opinion because depending on the patients, the background of the patient, the previous treatments and the NK cell level, and also depending on the immunologists, there are different treatments available. So, if we are talking about, for example, when we test immunology specifically in the uterus, and we find that the NK cells are a bit high, well, for that kind of patient, we recommend some medication called Neupogen, which is the granulocyte growth factor, and, normally, that kind of medication may help us in achieving pregnancy, but everything will depend on the immunologist because that kind of test has to be recommended by an immunologist, so we normally do not recommend that treatment, unless our immunologist decides to do so. It’s a very specific treatment and has to be prescribed by a very specific doctor.
It depends on two factors. First of all, consider what kind of clotting alteration the patient has, and secondly, I would say that it also depends on the haematologist who has already prescribed the heparin. So, in our experience, we normally recommend starting the heparin, the Clexane, at least one week before the eventual embryo transfer because, apart from the anticoagulant effect that the heparin has, we also know that it can also modulate the immune system, and it’s also useful to use it some days before the embryo transfer. Of course, it will also depend on the alteration the patient has, but in our experience, we normally recommend using it at least one week before the embryo transfer unless the patient does not have any kind of specific clotting issue and the immunologists also agree with that, but, normally, I would say that more than 90% of patients started heparin some days before the embryo transfer.
Well, it’s not the topic, but of course, it depends on the embryos. So, we don’t perform embryo transfer on day three anymore. We always try to push the embryos to reach the blastocyst state. What it may work is, for example, if we need to do the pgs on the embryos on day 5, it’s easier for the embryos and for the technician who is performing the embryo biopsy to do that assisted hatching doesn’t make a small hole in the external part of the embryo, to make the embryo start going out from that part, and it’s going to be easier for the biologists to take some cells. Apart from that, there is some data that the embryo has an external part quite thick. Sometimes, they have been found that it may help implantation, but it’s quite controversial also. So, as we do not perform embryo transfer on day three, in case the biologist recommends doing the assisted hatching, of course, they just do it, and it’s fine, but we always do transfer on blastocyst stage on day 5.
Well, as I mentioned before, it also depends on the immunologists, but what I can say is that we normally use prednisolone, and it’s used like from one week before the embryo transfer until week number 10 of pregnancy. After that moment, our immunologist recommends stopping it and then the Hydroxychloroquine, which also depends on her, so I think that many patients start taking the Hydroxychloroquine at least one month before the embryo transfer, and it’s kept for the first week of pregnancy. Depending on the alterations of the immune system and the patients, normally, that kind of medication is recommended to be stopped or kept for some more weeks, so it all depends on the immunologist’s opinion.
At least in Spain, intralipids are not very used. We normally prefer the intravenous immunoglobulin because the security profile is different, but of course, I’m not an immunologist, and our immunologists normally recommend using the intravenous immunoglobulins because the profile is better, and it’s quite well known the effects it may have and of course the results are almost the same, and it all depends on the immunologist’s opinion because this is not a medication that we normally prescribe, so, it all depends on what they recommend to use in that kind of patient.
We don’t use intralipids. We don’t use them, but what I can tell is that in case we need to use the immunoglobulin intravenously, we normally use the first dose before the embryo transfer, one day before the embryo transfer, or even the day of the embryo transfer, and then the second one is normally used on the day of the pregnancy test, in case the pregnancy test is positive. Afterwards, the next infusions are used every 3 or 4 weeks, depending on the patient.
They are not better or worse, it’s just a matter of preferences and well of course the experience that each immunologist has with each medication. In the end, we know that intravenous immunoglobulins are quite sure to be used, but of course, each kind of medication has to be followed by a specialist. So, in the end, each doctor prefers what they have been used to use in the end.
Actually, in my experience, we have used it for many years, and with many patients, and we didn’t find any side effects in any of the patients. Of course, each patient is different, but I think that the security profile it has is quite high, so, according to my experience, everything went well, and I don’t remember any patient that had any kind of side effect.
It depends on the patient’s background, and also on the immunological tests that normally are performed before recommending any treatment. So, in general, for patients with high NK cells in a blood sample, our immunologists give them the advice to be treated with that kind of immunoglobulins, and just in case, for example, the prednisolone is not enough, and the immune system can’t be under control in those kinds of patients.
Well, I think that in that patient, transferring 2 blastocyst embryos won’t add any benefit in the end because if the embryos were not tested, it’s not a matter of transferring one or more embryos. So, if the endometrial lining was fine, the ERA test was also fine, and of course, well a specific treatment regarding the high NK cells could be added or at least recommended, it would be much better than transferring 2 embryos because transferring 2 embryos won’t increase the pregnancy rate in that kind of patient. I wouldn’t recommend doing that.
Well, if the aspirin has any effect, normally, it has a positive effect. So, it’s true that aspirin may affect positively all that endometrium and vascularity and all the flow from the vessels from the endometrium. So, normally, the aspirin could have at least no effect or a positive effect. I wouldn’t say that it may have any negative effect. We know that many patients could benefit from using aspirin. We normally recommend using it in patients who have previously been tested for some clotting alterations. So, the idea of just using treatments, such as aspirin or heparin, in patients that need to use that kind of treatments because, for example, the aspirin, in case the patient gets pregnant, sometimes, in a very small amount, can go through the placenta. Of course, if it has to be used, it’s fine, but if this is not useful for that patient, we do not recommend using it for all patients.
I would never recommend a patient who has had the embryos previously tested transfer 2 embryos. Those blastocyst embryos, if they are healthy, have high implantation rates, so the idea is that that patient gets pregnant and has a healthy pregnancy and a healthy baby at home. So, transferring two embryos won’t add any benefit apart from increasing the risk of having a twin pregnancy at all. I would recommend just transferring 1 embryo for sure. 100% sure. I wouldn’t recommend transferring 2 embryos.
As I mentioned before, we do not add that kind of treatment because it has to be followed by the immunologist, depending on the patient. Some patients who have been using intravenous immunoglobulins must use them all the pregnancy and from week 10 on. It always depends on the immunologist. So, as far as I know, she normally recommends stopping suppression by that moment, and depending on the patient, if she needs to take any other medication, it is always recommended. But, as I mentioned before, we are gynaecologists, and we are not the ones who have to prescribe that kind of treatment. So, I guess that it depends on how the tests go, how the NK cells and all the immunological systems are doing, and, of course, how the pregnancy is doing.
It’s recommended to use it as close as possible to the transfer as possible because of the positive effect that we may find on patients, and it’s important to do the embryo transfer as soon as possible because if the positive effect is there, we need to do our best, and we need to take advantage of that. Try to do the embryo transfer as soon as possible. So, if it’s possible to do one month the treatment and then the next month the embryo transfer, that would be more than enough, and it would be the best option in that case.
There is no data regarding if it’s recommended in patients with high NK cells. What is known is that in some specific patients, doing that kind of scratch on the endometrium may try to activate the immune system, trying to, afterwards, have that immune system more balanced after the next embryo transfer. But it’s kind of controversial on that topic also because not all the papers have found the same results. So, in general, in our experiences that we had had, the endometrial scratching in some patients, we didn’t find any changes regarding implantation. Of course, each patient is different, and each case there has to be checked um individually. As far as I know, it’s not specifically recommended for that kind of patient.
Everything will depend on what we are talking about, if you are talking about blood and high blood and NK cells or lymphocytes, it, as I mentioned before, could be treated according to your immunologist’s recommendation, maybe with prednisolone or sometimes with immunoglobulins. So, everything will depend on the specific patient and the specific case itself. If we are talking about the endometrial NK cells, what is normally recommended is using that Neupogen, which is like a granulocyte colony growth factor, to try to put that immune system in balance. But, of course, as I mentioned before, those kinds of treatments are quite specific, and they are not commonly used in normal medical practice. So, depending on the laboratory that is testing that kind of cells, they always recommend a specific treatment, depending on the uterine NK cells that they found in the sample, and also depending on the patient’s background because that kind of person is so specific, that we need to have a good approach of what to do with them in the end. We normally use that kind of medication.
Normally, if they don’t have any kind of issue regarding insulin, if they are not overweight, we don’t use metformin in general, just in cases of patients that need to use it, but not in general.
As I would say, almost everything in our life, small doses of vitamins and so on, could be beneficial. Why not. But maybe a higher dose, we do not know the effect it may have. Turmeric, we know it’s a very powerful antioxidant, so taking some small doses of it, of course, may not have an effect, but, in the end, taking very high doses of, I would say, almost all the vitamins could cause an effect. We don’t know if it could be negative or not, but I would recommend having a healthy way of life during the two weeks after the embryo transfer, and when you are waiting for the eventual pregnancy test, I will not try to change a lot the way we normally eat or take vitamins.
It depends on the patients. When we are talking about adenomyosis, we normally prefer to use Decapeptyl, which is an agonist of the gonadotropin hormone, and for three months because it has been related to better pregnancy chances. So, what we normally recommend is doing that way, we don’t normally use the Letrozole at all.
It’s normally prescribed by our immunologist, and it’s just specifically used in a very specific number of patients because that patient has to be under control due to some kind of alterations in the blood cell count and so on. But when it is recommended, of course, we use it.
The main issue with adenomyosis is that it’s also clear how it could be improved in the end and how to increase the implantation rate in that kind of patient. So, we have kind of plenty of experience using Decapeptyl, and we have patients who used Decapeptyl due to adenomyosis, and some of them got pregnant. Of course, some others didn’t. So, in the end, it’s very difficult to know exactly what’s going on in the uterus in a patient with that kind of issue, but at least we have some data that helped us in deciding that maybe Decapeptyl was quite useful for us and, as I mentioned before, we use it in several places, and we got good results, but we don’t know if it was exactly just for Decapeptyl or because it was the moment for that patient to get pregnant.
It’s an excellent question. We know that hormonal medication could affect us, so that’s the reason I mentioned before that it’s really important to use the same medication that we are going to use in the next embryo transfer. It means that if we are doing, for example, a treatment with just estrogen and progesterone, we need to use the same for the next embryo transfer. The same happens with heparin. Heparin is known to impact, or at least it’s suspected to impact, the window of implantation. So, if a patient has to add heparin to the treatment due to any clotting alteration, we already recommend using it when we do the ERA test and also with the embryo transfer. So, if the patient has to add heparin, let’s say one week before the embryo transfer, we will recommend using it also for the ERA test and then stopping it. Regarding the age, it is not related to the window of implantation results.
I would recommend using it for three months, and we use one injection every month. After stopping Decapeptyl you don’t need to wait, so after the effect ends like one month after using the injection, the patient starts menstruating again, and at that moment we kind of start the protocol to prepare the uterus or whatever to do the eventual next embryo transfer.
Yes. There is like quite a high amount of data regarding heparin, Clexane and other kinds of heparin in general. It’s known that it may help patients, especially those that have been tested for several clotting alterations such as thrombophilia or any other anti-antiphospholipid syndrome, so they normally need to use whether the Clexane or heparin, trying to increase the implantation and the pregnancy rate. So, in patients who had several miscarriages and who tested positive for that kind of alteration, of course, Clexane may help.
Everything will depend on what kind of issues that patient has. If it’s just an alteration of the clotting, we normally add heparin or aspirin, and depending on the alterations, the immunological tests test, sometimes, if we need to add prednisone or other, we always follow our immunologist’s recommendation. As I mentioned before, we are gynaecologists, and we are not able to prescribe any kind of prednisone or whatever because it has to be prescribed by someone who knows exactly why they can be useful.
It will depend on what kind of laparoscopy and the reason for doing that. Maybe the patient had a benign cyst in the uterus, and it was a laparoscopy to remove that would not be very important, but for example, if the patient had surgery to remove an endometriosis cyst, it could be a more complicated surgery. So, I recommend at least one month to do any kind of test in general, trying to make the immune system in the body and the basal conditions start from the beginning to do the tests that are required.
Yes. I will recommend one month and a half.
In the end, it’s just an immune system imbalance. Of course, it’s very difficult to know exactly the reason a patient has that increase in NK cell numbers, and it’s impossible to know. So, we know that the immune system is not working or at least we suspect that it’s not working as it should be, but nothing more. It’s impossible to know why a patient had or has that kind of alteration and why others haven’t.
We normally use prednisone. We use prednisone, and we take around 10 milligrams per day, so it’s not very common to have a patient who takes more. Of course, it also depends on the body mass index and so on. Normally, the most common dose is 10 milligrams.
There are two different types of steroids, and depending on the effect we want to have and also on the experience that the doctor who is prescribing it has, we recommend one or the other. In Spain, the most common one is the prednisone.
Exactly. The anti-Tpo, which are antibodies against the thyroid, we normally test them in the first consultation because it’s quite common to find patients with some kind of thyroid issues. We test directly for all the patients. and the EMMA test is a very specific immunological test that we request for patients.
This question is almost impossible to be asked to answer also because it’s not just a matter of saying okay, I’m going to add an immunological treatment, and what is my pregnancy test because each patient is different. Not all patients receive the same treatment. What we have seen is that patients who followed an immunological treatment. Of course, if we are talking about egg donation treatment or testing the embryo for transferring, the results are better, but I would like to clarify that not all the patients do the exact treatment, so if we are talking just in general, it’s impossible to answer that question because we have seen that we improve all our results after the immunological treatment, but it’s not just a matter of adding a specific treatment or not, it’s a matter of doing any other examination, as we mentioned before, regarding the ERA test in case it’s needed, or trying to do our best to have the best embryo to transfer and a healthy embryo also. So, it’s difficult to know exactly the pregnancy rate in each patient because each patient is different.
We normally recommend the patient that we have been in touch with before going to our immunologist’s consultation. Some tests could be required and requested for ourselves, and then in case the immunologist decides that some others could also be necessary, of course, she will let the patients know. We work as a team, so it can be like a consultation could be almost at the same time. We check the gynaecological part, and then, of course, our immunologist will require the test that she recommends to each patient of course, she will add the specific treatment, and she will see things that could help that patient, but we work in a team. Of course, she will be focused on her part, and we will be focused on ours, so in the end, we try to do everything together, we discuss patients, but the consultations are separate.
The main issue with the kind of cells is that having that kind of cells high in the blood doesn’t mean that you would have them high in the uterus, and the same happens in the opposite situation, If you have NK cells high in the uterus, it doesn’t mean that in the blood would be the same. We know that some cells are just in the uterus, and others are circulating in the blood, but it doesn’t mean that they have to be related to the others. So, it’s impossible to know at this moment how frequent is having both situations at the same time because, as I mentioned before, it is kind of a controversial topic. After all, not all the papers have found the same situation in blood and the uterus.
At first, it was just tested the blood uterine NK cells, but not uterine ones, and then they realised that maybe it was not the same situation in the uterus. That’s the reason they also started checking the uterine NK cells. We know that there have been NK cells in the uterus, but it’s very difficult to know if you have some cells, if it’s fine or if it’s too much. So, in the end, it’s a very difficult situation to deal with because it’s very difficult to know exactly if the number of NK cells that a patient may have in the uterus could harm implantation, which is what we need to know.
I don’t know what’s Prostap. I think that maybe it’s a brand. Well, actually, it’s not a Spanish brand of any treatment, so I can’t say if it’s the same or not because Decapeptyl is also a brand, so maybe it’s not the same.
As I mentioned before, it will depend on the alteration that could be found in the test, so if there is a clothing alteration, normally it is prescribed for at least the first trimester and depending on the patients and the previous miscarriages and so on. Sometimes it has to be kept throughout the pregnancy, and sometimes even after giving birth, so it’s quite common that patients have to follow that kind of treatment for the pregnancy.
As far as we know, as we mentioned before, it’s true that heparin may affect the implantation window, and it’s the reason why I finally recommend adding it to the treatment in case the patient has to use it for any reason. However, we do not normally recommend using prednisolone or hydroxychloroquine because it’s not known if it affects the window of implantation. It’s known that, at least at the moment, it doesn’t affect the window of implantation, and that’s the reason why we do not recommend using them in patients who have already been recommended to use them before doing the embryo transfer. We just add the heparin in patients who normally have to use it.
There are two different alterations in the immunological system. It’s known that celiac disease may also affect the implantation rate and also the failure of implantation. That’s the reason why, when we have to deal with a patient that has that failure of implantation, we always request to do the select disease to make sure that everything is fine in that way because it’s not related to them high NK cells, but it’s also a part of the immune system that has to be in balance in case it’s not.
It would be exactly the opposite. In case the Neupogen has an effect, it would decrease the kind of cells in the uterus. That’s the reason why that is the treatment most commonly used in patients who have that issue. Neupogens try to put the immune system in balance. So, it doesn’t help to increase the NK cells.
There are no data regarding that, and it’s not related, so we do not recommend it, well, we don’t add the kind of treatment in the patients that are undergoing the era. We just added heparin because it’s what we know that it may affect implantation. But it’s true that some patients, for example, didn’t use heparin because they didn’t know that they had to use it when they performed the ERA test, and then, of course, we couldn’t use it, we had the same good results after using the ERA test. So, it’s possible to know it in advance because we know that it may affect the gene expression, but in my experience, we had some patients who didn’t add the heparin before, and we also had good results in the end.
We just remove some kind of food from the diet. It is like having a gluten-free diet, and that’s enough.
It’s kind of a difficult topic to explain. We know that there are some receptors in the NK cells which are the cure and some others that are like in the embryo and some other parts of the uterus, so the idea is that some kind of patients may have a specific type of cure, a receptor, in the uterine NK cells, or actually in the general NK cells, and that patient may have like an increased risk of some adverse outcomes in their pregnancy and also may have an increased rate of miscarriage or failure of implantation. We know that the combination between the KIR AA and the HLA from the embryo, which is C2C2, is the most difficult combination between them. The reason is that KIR AA makes that embryo implant with lower chances. Apart from that, it is known that it is also related to some kind of pregnancy outcomes regarding preeclampsia and also some other alterations during pregnancy. So, in a very specific group of patients that have immunological system issues, we normally test that cure and the system in both the patient and her partner. We normally recommend testing the HLA system to try to clarify if there is any kind of incompatibility between them. In case we find that kind of incompatibility, some specific treatments could be added to the normal treatment to try to avoid any risks during pregnancy and try to reduce also the miscarriage rate.
And regarding the last question, if the KIR system and the HLA of the father count, of course, it counts. As I mentioned before, we always test the HLA in the father, in the partner of the patient, and also in the patient, so it’s like that kind of test should be requested by the immunologist because in case some alteration is found, it’s very important and to be like on very specific women and not all them, it’s not just a matter of having a good or a bad cure system or not, it’s just a combination because it’s known that some of them could affect negatively or at least could increase some kind of effect during pregnancy. While some others are not affected at all, it doesn’t happen just with the KIR AA, for example. Sometimes, other patients with different cure systems could also have an increased risk of alterations during pregnancy or even a lower pregnancy rate. That’s the reason why that kind of test should be requested in very specific patients and also always under an immunologist’s recommendation, not just in general for all patients.
It depends if, for example, we have the chance to choose a donor with a specific HLA system, it would be the best option because many patients are undergoing egg donation treatments. We can also test the HLA on the donors, and they can also be tested for that kind of specific alternative system. We normally find a suitable donor for the patients, and for many patients that have some cure system issues, we normally need to select a specific HLA donor. Furthermore, we normally use a c1c1 donor, but we have other patients that, in contrast, need c2c2 donors, so, in the end, everything will depend on the combination, and our immunologist always recommends, in case we need to search for a very specific donor, to try to select a good donor also in an immunological way and when we don’t have the chance of selecting a donor, because the patient is undergoing the treatment with their own eggs, then normally some specific treatments, such as Neupogen or sometimes prednisone, have to be used. So, everything will depend on the exact alteration the patient may be found to carry, and in that situation, our immunologist recommends the specific treatment to follow.
There are two different issues. Two different things. When we talk about euploid blastocysts, it means that the embryo is healthy and chromosomally, so we know that the chromosomes are fine. It means that, for example, the embryo does not have any issue regarding Down syndrome or some others, but it doesn’t have anything to do with the cure system. So when we test the embryos in a PGS or a PGT-A, we always make sure that the embryo is healthy and that the chromosomes are fine, but it doesn’t mean that the embryo will implant, so of course, one of the main reasons why the embryos don’t implant, is the embryo itself.
But if the embryo is healthy, we know we have almost half of the way done, but we need to also have a good endometrial thickness and so on. So that it’s not so easy as just having that perfect embryo. Also, in some very specific kinds of patients, sometimes the embryos have to be already tested by that, and for that kind of HLA system, which is a very specific treatment, it’s very uncommon to be needed, but in general, they are two different things. It’s important to have an euploid embryo, of course, but it doesn’t have anything to do with the cure system of the embryo.
No, it’s different. We are talking if we are testing the NK cells; it’s just the amount, and if we are testing the cure, it is the receptors that cells have on the surface of the cell itself. So, it’s not related, but what is true is that when we take advantage and when we do very specific immunological tests, we prefer to do all of them not because they are related but because maybe we know that they are not related, but it’s just a matter of having like a complete examination on that patient and being sure that we have all that immune issues under control.
No. We do a complete HLA testing and of course, as I have been saying before, it all depends on the immunological recommendation.
What is recommended, at least at this moment, is waiting around one month to get pregnant, but there are no data regarding the immune treatment. So, it doesn’t matter if it’s the COVID-19 vaccine or some other vaccine. I would recommend not using both treatments at the same time. I would recommend using the vaccination and then starting the treatment that you are following. But I would recommend waiting around one month to get pregnant to try to have the immune system in the best conditions.
I would recommend exactly the opposite, I would recommend getting the vaccine to everyone. As I mentioned before, the vaccination now, if you are using the Pfizer vaccine, it takes less than one month to have the complete vaccination protocol. So, I would recommend that everyone get the vaccine and then maybe wait one month to start the treatment. There is no data if we are talking about egg freezing, for example, that the vaccine could affect the egg quality or so on, so you can do everything more or less at the same time. But if we are talking about doing an eventual embryo transfer, we might recommend waiting until the complete vaccination protocol has been done.
It’s different because the microbiome is the totality of bacteria. The plasmatic cells may count because we know that when we are talking about infection, it’s quite common to have that kind of cells in a high amount in the endometrium. So it’s quite related to the infection of that kind of plasmatic cell. But if we want to clarify exactly the species and the bacteria, we have inside the uterus. It’s important to ask for it. Otherwise, if we know that we have no, for example, plasmatic cells over, and the plasmatic cells are high, it just makes us suspect that maybe that patient may have an infection. But we need firstly to clarify what kind of infection is in that patient or, apart from that, if the number of lactobacilli species that that patient has is the normal one. So it’s a different test to be requested.
No, it’s not related.
We know that the stimulation itself doesn’t affect the antibodies that we can find in blood. So, what we know is that the thyroid function could be slightly altered due to the stimulation, not the stimulation itself. It’s more the hormonal medication and the hormonal balance that could also affect the thyroid because the thyroid and hormones and the ovarian hormones are quite related to one another. So, the stimulus itself won’t affect the antibodies because antibodies are not related to the stimulation. If a patient has negative antibodies, it’s fine. But if they test positive, we need to take care and be careful with the TSH level because we know that TSH can vary a lot during the stimulation, especially in patients with positive antibodies.
I will be honest; we don’t use any of those. We work with a Spanish laboratory, and we have done several tests with them, and we are using that test.
Well, that kind of mutation is really common to be found in the general population. We know that around 50 % of people may have that alteration, that kind of thrombophilia mutation, so having just that mutation is not related to any inflammation failure or miscarriages in general. But if we have a patient that had previous miscarriages or had a previous failure of implantation, it’s important to consider it. So, in case we just find that alteration, we normally add folic acid, which is the first airline option, and then in some patients, normally need to be added heparin or even heparin and aspirin. It’s the most common treatment to follow.
Well, I would need to know a little bit about the patient, but in general, the main issue with that kind of treatment is that it’s not so easy to give strong evidence regarding some kind of treatment. In general, some immunological treatments are used, and we have good results, but it’s difficult to know exactly if in that patient we will have such results. So, it’s very difficult for me to advise that patient because, of course, I would need to have much more about her.
It depends on the laboratory that performs the test because the range may vary between laboratories. So, if they are positive for that laboratory, it doesn’t mean that it’s a very strong immune issue, it’s just a matter that we know that those antibodies are positive, and we need to take care of that patient’s thyroid function because they are at risk of having some alterations in the TSH level, and it’s important to have the TSH under control as much as we can. Otherwise, we may find some problems, say, afterwards, so it’s not a matter of how high that thyroid antibodies are, it’s just a matter of saying, okay, they are positive for the laboratory, or they aren’t. If they are positive, we need to take care of the TSH level.
If the period that they are used is short, I would say that, of course, the estrogens have all the medication, all the hormones have some side effects, but the most common ones are headache and some kind of slight belly pain, and so on. But side effects are not very common, and, of course, they are not very severe. All medications may have side effects, so we need to be ready to try to use the medication just when we need to use it for that kind of treatment. We have much experience with patients who have to undergo several treatments and have been using destroyers several times, several months, and we didn’t find any severe side effects on that basis, but, of course, the less, the better. So, we are talking about hormones. We are talking about medication. So, if it’s possible to achieve good results in two months, it’s better than using them for 10 months, of course.
I would say yes because it doesn’t matter what kind of medication we are using, but most of the drugs we use have to go directly to the blood, and the liver is the organ that will clean that blood from that kind of issue. So, sometimes, if some patients are more sensitive to some kind of treatment, they may have liver values a bit higher. So we don’t see it very commonly, but sometimes I have seen patients with an increase in the liver and enzymes after doing the treatment or after using some specific medication. Normally, when we stop it, the liver function goes back to normal and the previous situation and nothing important happens.
It’s not very common. Some patients have a slight increase in bilirubin levels, and it’s something quite common to find, especially in young patients, it’s something called the Gilbert syndrome, which is quite typically found in patients. We just see a slight increase of the bilirubin, but it doesn’t affect all the patients, and it doesn’t have any negative effect, but, in the end, as I mentioned before, when we’re talking about hormones and medication in general, some parts of the body could also be affected by the medication we are using. In general, the stimulation does not affect the bilirubin level, but, of course, it could affect some patients why not.
There is some data regarding letrozole and those kinds of treatment that could try to decrease destroying levels that could affect negativity to endometriosis. So, of course, it could be helpful in the end, sometimes, endometriosis is a very difficult illness to deal with, and many treatments have been tested to try to improve their results regarding fertility and also to improve all the normal and daily conditions of the patient. So, of course, it could also be helpful.
We test it before the embryo transfer, so if she has positive antibodies at least when she’s starting the preparation for the eventual frozen embryo transfer or even is starting the stimulation, normally, we recommend testing it at that moment, trying to be sure that the TSH is fine, and after doing the embryo transfer, depending on the patient, we normally test and again the TSH with the pregnancy test at the same time. If the pregnancy test is positive and if the TSH is fine, we recommend testing it maybe two weeks afterwards, trying to have that patient under control and trying to do our best in that way.
After the embryo transfer, we normally recommend doing it once we do the pregnancy test in blood. When you do it, and if it’s fine, sometimes after two weeks, that normally takes place at the same time as the first vaginal scan that we do in the consultation, depending on the patient. Since we do not handle the entire pregnancy follow-up, we generally recommend testing TSH in each trimester. However, for patients with positive antibodies, more frequent monitoring may be necessary due to their increased risk of thyroid dysfunction.
