Low molecular weight heparin and recurrent Implantation failure

1
Low molecular weight heparin and recurrent
Implantation failure
Michael Kupferminc Head of Maernal Fetal Division
Department of Obstetrics and Gynecology Lis
Maternity Hospital Tel Aviv Medical Center Tel
Aviv University
2
Antithrombotic therapy for improving maternal or
infant health outcomes in women considered at
risk of placental dysfunction. Cochrane Database
Rev. 2013 .

• Treatment with LMWH for women considered to be at
  particularly high risk of adverse pregnancy
  complications secondary to placental
  insufficiency was associated with a statistically
  significant reduction in risk of perinatal
  mortality, preterm birth before 34, preeclampsia,
  and infant birthweight lt 10th centile, when
  compared with no treatment for women considered
  at increased risk of placental dysfunction.

3
Meta-analysis of low molecular weight heparin to
prevent recurrent placenta-mediated pregnancy
complications. Rodger MA et al. blood 2014.

• A meta-analysis of 6 RCTs, with total of 848
  pregnant women comparing LMWH versus no LMWH for
  the prevention of recurrent preeclampsia, IUGR lt
  10th , placental abruption, or IUFD gt20 weeks.
• Overall, 67/358 (18.7) of women on prophylactic
  LMWH had recurrent complications, as compared
  with 127/296 (42.9) women with no LMWH RR
  reduction 0.52 (95 CI 0.32-0.86) (p0.01).
  Decrease of 54.
• RR reductions with LMWH included any PE, severe
  PE, SGA lt10th, SGA lt5th, preterm delivery lt37
  weeks and preterm delivery lt34 weeks.

4
IVF failure
5
Recurrent implantation failure

• Growth hormone (non significantNS)
• Androgen supplementation- NS
• Steroids (650 IVF OR 1.5 CI 1.05-2.13)
• Endometrial response Sildenafil (viagra), (some
  promising results) Aspirin (negative
  meta-analysis, endometrial biopsy (debate).
• Antioxidants- negative meta-analysis.
• Embryonic factors assisted hatching (low OR) no
  change in LBR.

6
Effect of heparion on trophoblast invasion
7
Effect of heparin/LMW heparin on implantaion

• The implantation is a complex process initiated
  by the recognition and adhesion between the
  embryo surface and the uterine endometrial .
• LMWH blocks P-selectin and L-selectin and
  determines its most potent anti-inflammatory
  property. The selectin adhesion system may
  constitute an initial step in the implantation
  process.

8
Effect of heparin/LMW heparin on implantaion

• Cadherins are a group of glycoproteins for the
  calcium-depedent cell-to-cell adhesion mechanism.
• Enoxaparin have recently been shown to
  down-regulate placental E-cadherin expression
  and, consequently, cell-to cell adhesion,
  enhancing trophoblast capability to invade
  endometrial cells and proliferate. This improves
  throphoblast invasion since E-cadherin
  down-regulation increase throphoblast invasion.

9

• This provides a possible mechanism by which
  heparin could promote trophoblast cell
  differentiation and motility.
• Insulin-like growth factors I (IGF-I) and II
  (IGF-II) are potent mitogenic and
  differentiation-promoting factors which are
  implicated in implantation and fetal development.
  
• LMWH increases free IGF-I in a dose-dependent
  manner and thus promote trophoblast invasion.
  Similarly, increased expression of IGF-II
  facilitate human extravillous cytotrophoblast
  cells invading the decidua and its vasculature.

10

• LMWH alter also trophoblast proliferation and
  invasion through effect on various cytokines such
  as TGF-b1, IL-1, IL-11, GM-CSF.
• LMWH at therapeutic doses induces trophoblast
  MMP-2 and MMP-9 transcription and protein
  expression. Therefore, LMWH appears capable of
  improving the invasive capacity of trophoblast
  cells by regulating their degradative capacity.
• Heparin-binding epidermal growth factor
  (EGF)-like growth factor (HB-EGF), is a potent
  growth factor for enhancing the development of
  IVF-derived embryos to blastocysts and subsequent
  zona hatching .
• LMWH potentiate HB-EGF binding, and also
  up-regulate HB-EGF, thus LMWH again, enhances
  extravillous trophoblast differentiation and
  invasive activity.

11
Rimon E. and Kupferminc M. In press

• Enoxaparin significantly protects throphoblasts
  from hypoxic injury on throphobnlasts
  differentiation.
• The influence of Enoxaparin on trophoblasts
  apoptosis suggests that Enoxaparin may prevent
  apoptosis in trophoblasts exposed to hypoxia/
  apoptosis induced factors.
• LMWH attenuates LAC sera-induced apoptosis on
  placental explant cultures and facilitate
  trophoblast invasion providing protective
  placental mechanisms exerted by heparin.

12

• LT- APS treated with LMWH and normal implantation
• RT-APS not treated with LMWH and abnormal
• implantation

13
Qublan et al., LMWH in the treatment of
recurrent IVF-ET failure and thrombophilia a
prospective randomized placebo-controlled trial.
Hum Fertil 2008

• To determine the effect and safety of
  thromboprophylaxis using LMWH in women with
  recurrent IVF-ET failure and thrombophilia.
• 83 women with history of gt3 or more previous IVF
  failures and who had at least one thrombophilic
  defect were randomly allocated into two groups
  Group A (n 42) received enoxaparin 40 mg/day,
  and group B (n 41) received placebo (NaCl
  0.9). Both treatments started on the day of ET.
• The primary outcomes were the implantation,
  pregnancy and live birth rates.

14
LMWH in the treatment of recurrent IVF-ET
failure and thrombophilia a prospective
randomized placebo-controlled trial. Qublan et
al., Hum Fertil 2008

• Patients who received LMWH had a significant
  increase in the implantation and pregnancy rates
  compared with the placebo group (20.9 vs. 6.1
  and 31 vs. 9.6, respectively p lt 0.001 and p lt
  0.05, respectively).
• A significant increase in the live birth rate
  was observed in the LMWH group compared with
  placebo (23.8 vs. 2.8, respectively p lt 0.05).
  The abortion rate was significantly higher in the
  placebo-treated group compared to the LMWH group
  (p lt 0.05).

15
Management of 273 cases of recurrent implantation
failure results of a combined evidence-based
protocol.Sharif KW, Ghunaim S. Reprod Biomed
Online 2010

• Patients with apparently unexplained recurrent
  implantation failure in IVF/ICSI (gt 2 or more
  failed cycles, during which at least six
  good-quality embryos were transferred).
• A prospective cohort study and included 273
  couples with recurrent implantation failure.
  Each patient underwent a pre-treatment work-up,
  consisting of pelvic US for hydrosalpinx,
  hysteroscopy and screening for thrombophilia.
• Detected abnormalities were dealt with
  accordingly proximal occlusion for hydrosalpinx,
  hysteroscopic management for intrauterine
  pathology and thromboprophylaxis with daily LMWH
  from the day of embryo transfer for
  thrombophilia.

16
Management of 273 cases of recurrent implantation
failure results of a combined evidence-based
protocol.Sharif KW, Ghunaim S. Reprod Biomed
Online 2010

• The patients then underwent IVF/ICSI with
  laser-assisted hatching. 112 patients (41 group
  1) had abnormalities detected (17 hydrosalpinx,
  11 intrauterine pathology, 63 congenital
  thrombophilia, 21 acquired thrombophilia) and the
  remaining 161 (59 group 2) had normal work-up.
• The pregnancy rates per cycle started for all
  patients, group 1 and group 2 were 47, 55 and
  41, respectively. This suggests that using the
  described management protocol in couples with
  previous recurrent implantation failure leads to
  a favorable chance of success.
• Administration of LMWH to women with
  thrombophiloias could contribute to higher
  clinical pregnancy rate in the group with
  abnormalities compared to 35 in the group with
  normal workup (p0.01).

17

• 150 women with gt or 2 failed assisted
  reproduction treatment cycles were included in
  this randomized open-label pilot trial. The
  authors excluded inherited and acquired
  thrombophilia. Along protocol was appplied and
  ICSI performed in all cases. Enoxaparin (1mg/kg)
  was given to 75 women from oocyte retrieval up to
  12 weeks. The control group did not get
  enoxaparin.

18

• Overall outcomes.LMWH, low molecular weight
  heparin.

• 34.7

• 26.7

• Urman B et al. Hum. Reprod. 2009241640-1647

19

• The observed relative increase by 30 in live
  birth rates with LMWH may be regarded as
  clinically significant trend necessitating
  further research.!!!

20

• Subgroup analysis for women with gt 3 RIF 37 cases
  and 34 controls shows 35 increase in LBR.

21
The role of LMWH in recurrent implantaion
failure a qausi-randomised controlled study.
Berker et al. Fertil Steril 2011

• 110 women with consecutive 2 recurrent
  implantation failure who used LMWH empirically
  And 109 same
• patients but who did not get LMWH. Subgroup
  analysis for gt 3 RIF, 48 cases and 43 cases. All
  screened negative for coagulation and
  immunological causes.
• In Subgroup analysis the clinical pregnancy rate
  (CPR) and life birth rate (LBR) were 35.4 and
  31.2 in the LMWH group and 27.9 and 23.2 in
  the control group. Increase in LBR of 25.

22
Prednisolone and LMWH in patients with failed
IVF/ICSI Cycles a preliminary report of a
clinical trial. Siristatidis et al. Human
Fertility 2013

• 52 women with 3 gt RIF. Group 1 LMWH and
  prednisolone. Group 2 LMWH . Group 3 no
  treatment. Increase of 50 from 3 to 2.

• 33.3

• 22.2

• 14.3

23
Noci et al., effect of daltaparin sodium
administration on IVF outcome in
non-thrombophilic young women. Reprod Biomed
Online 2011

• 172 women lt 40 years, negative for
  thrombophilias, who underwent their first IVF
  cycle, were randomly allocated to treatment
  (n86) and control (86). Women allocated to
  treatment received daltaparin from oocyte
  retrieval up to 9 weeks of pregnancy.
• The clinical pregnancy rate/ET were 26 in the
  treatment group and 20 in the control group with
  live birth rates of 21 and 16. Despite lack of
  statistical significance, the increase in
  pregnancies in the treatment group may be
  considered important clinical point in the
  optimization of IVF clinical outcome.

24
LMWH in women with repeated implantaion
failure. Lodigiani et al. Women Health 2011.

• Analysis of patients with at least two IVF/icsi
  cycles with
• implantation failure, and submitted to
  further ART cycles with or without
  administration of LMWH.
• In total 105 clinical pregnancies were observed
  in 569 cycles 18.8). Pregnancy rate was 17.19
  (88/512) in patients not treated with LMWH and
  29.52 (17/57) in the LMWH-treated group (p
  0.006).
• In women over 36 years of age pregnancy rate was
  15.5 in non-treated vs. 35.7 in treated cycles
  (p 0.007).

25
LMWH in women with repeated implantaion
failure. Lodigiani et al. Women Health 2011.

• Significantly higher pregnancy rate in patients
  with previous ART implantation failures was
  observed with LMWH. The results confirm no
  relation among inherited thrombophilia and
  pregnancy rate in patients with previous IVF
  implantation failures.

26
Heparin for assisted reproduction (Review)
Cochrane Aug 2013

• Objectives To investigate whether the
  administration of heparin around the time of
  implantation (peri-implantation heparin) improves
  clinical outcomes in subfertile women undergoing
  assisted reproduction.
• Selection criteria All randomised controlled
  trials (RCTs) were included where
  peri-implantation heparin was given during
  assisted reproduction. Peri-implantation LMWH
  during IVF/ICSI was given at or after egg
  collection or at embryo transfer in the included
  studies. Live birth rate was the primary outcome.

27
Heparin for assisted reproduction (Review)
Cochrane Aug 2013

• Main results Three RCTs (involving 386 women)
  were included in the review. Peri-implantation
  LMWH administration was associated with a
  significant improvement in live birth rate
  compared with placebo or no LMWH (from 17.35 to
  27.1) OR 1.77, 95 CI,
• 1.07 to 2.90.
• There was also a significant improvement in the
  clinical pregnancy rate with use of LMWH (from
  25 to 34.9), OR 1.61, 95 CI 1.03 to 2.53.

28
Heparin for assisted reproduction (Review)
Cochrane Aug 2013

• However, LMWH did cause adverse effects including
  bruising, ecchymosis, bleeding, thrombocytopenia
  and allergic reactions with no serious
  consequences in one study but not in the other 2
  studies.
• Authors conclusions The results of this Cochrane
  review of three randomised controlled trials with
  a total of 386 women suggested that
  peri-implantation LMWH in ART cycles improve LBR
  in women undergoing assisted reproduction.
  However, these results were dependent on small
  studies.

29
Heparin for assisted reproduction (Review)
Cochrane Aug 2013

• These findings need to be further investigated
  with well-designed, adequately powered,
  double-blind, randomised, placebo-controlled,
  multicentre trials.

30
Adjunct low-molecular-weight heparin to
improve live birth rate after recurrent
implantation failure a systematic review and
meta-analysis. Human Reproduction update 2013

• 2 RCTs and one quasi-randomized trial met the
  inclusion criteria. One study included women with
  at least one thrombophilia ( Qublan et al., 2008)
  and two studies included women with unexplained
  RIF ( Urman et al., 2009 Berker et al., 2011).
• Pooled risk ratios in women with 3 RIF (N
  245) showed a significant improvement in the LBR
  (29 vs.19) (risk ratio (RR) 1.79, 95 CI
  1.10-2.90, P 0.02) and a reduction in the
  miscarriage rate (8 vs.28) (RR 0.22, 95 CI
  0.06-0.78, P 0.02) with LMWH compared with
  controls.

31
Adjunct low-molecular-weight heparin to
improve live birth rate after recurrent
implantation failure a systematic review and
meta-analysis. Human Reproduction update 2013

• The IR for 3 RIF (N 674) showed a trend
  toward improvement (RR 1.73, 95 CI 0.98-3.03,
  P 0.06) with LMWH.
• The summary analysis for the numbers needed to be
  treated with LMWH showed that approximately eight
  women would require treatment to achieve one
  extra live birth.

32
Adjunct low-molecular-weight heparin to
improve live birth rate after recurrent
implantation failure a systematic review and
meta-analysis. Human Reproduction update 2013

• CONCLUSIONS In women with 3 RIF, the use of
  adjunct LMWH significantly improves LBR by 79
  compared with the control group.
• However, this is to be considered with caution,
  since the overall number of participants in the
  studies was small. Further evidence from
  adequately powered multi-centered RCTs is
  required. This review highlights the need for
  future basic science and clinical research in
  this important field.

33
Thank you
34
Aspirin and/or heparin for women with unexplained
recurrent miscarriage with or without inherited
thrombophilia (Review).Cochrane Database Rev.
2014 .

• A trend towards a significant effect from LMWH
  when
• compared to aspirin (risk ratio (RR) of live
  birth 1.21, 95 confidence interval (CI) 0.79 to
  1.87) and of LMWH and aspirin when compared to no
  treatment (RR of live birth 1.25, 95 CI 0.74 to
  2.12) was observed in women with inherited
  thrombophilia
• but the subgroups were underpowered for firm
  conclusions. As the clinical question of efficacy
  of anticoagulants for women with recurrent
  miscarriage (RM) and inherited thrombophilia
  remains relevant, randomised controlled trials
  focusing on women with
• inherited thrombophilia only are urgently
  needed.

35
Aspirin and/or heparin for women with unexplained
recurrent miscarriage with or without inherited
thrombophilia (Review).Cochrane Database Rev.
2014 .

• In subgroup analyses of women with no previous
  live birth, a beneficial effect of LMWH over
  aspirin was found in pooled analyses of two
  studies (n 112, RR 1.24, 95CI 1.02 to 1.49).
  Some evidence of a similar trend toward a
  beneficial effect for LMWH versus LMWH and
  aspirin was observed in a small subgroup in one
  study (n 72, RR of live birth in women treated
  with LMWH and aspirin 0.77, 95 CI 0.59 to 1.02).

36
Kupferminc. Personal Data

• 219 women women with 2 gtchemical IVF pregnancies.
• Of 124 with 2 chemical pregnancies 50 had
  thrombophilias, and 74 no. Clinical pregnancy
  rate 48 in the thrombophilia group (24) and 33
  (25) in the non thrombophilia p0.03.
• Subgroup of 95 with 3 gt chemical pregnancies.
  30 with thrombophilias and 65 not. Clinical
  pregnancy rate
• was 60 in the thromophilia group and 37 in
  the non thrombophilia group. P 0.04.