Utility of hysteroscopy in not only diagnosis but also treatment of infertility,one of its causes being recurrent implantation failure.

1. Role of
hysteroscopy in
Recurrent
implantation
failure

2. Embryo implantation-
mechanism

3.  Morphological and molecular events from
fertilization to implantation
- Journey through fallopian tube (4-5 days in natural conception)
- Rolling inside the uterine cavity for a favourable site for implantation,
hatching of blastocyst and signalling the endometrium for preparation of
implantation
- Apposition
- Adhesion
- Penetration
- Invasion

4. • After rolling through the fallopian tube (natural conception) or through an embryo
transfer catheter (in case of IVF),the embryo moves within the uterine lumen by
rhythmic myometrial contraction,bathed in uterine secretion rich in glycogen and
mucin,which serves as nutrient for the floating embryo till it comes in contact with
the uterine lining.
• On reaching the uterine cavity,it becomes a blastocyst; rolls within the lumen for 1-
2 days in search of optimum site for apposition.
• During this phase,chemokines secreted locally by both endometrium and blastocyst,
such as Interleukin-8 (IL-8), Regulated on Activation of Normal T-cell Expressed
and Secreted (RANTES), Monocyte Chemotactic Factor (MCF) help to drive
blastocyst towards the area of endometrium which has acquired maximum
receptivity potential.
• MUC-1, a glycoprotein from the receptive endometrium,prevents blastocyst
landing up for apposition at improper non-receptive area of endometrium.
• At the optimum site of implantation,blastocyst binds with L-selectin (a
glycoprotein produced by endometrium)

5. • By this time hatching of blastocyst has been completed.
• Apposition of hatched blastocyst occurs through MECA-79,a
carbohydrate ligand of L-selectin.
• MECA-79 is upregulated from day of ovulation to a peak level-
6 days post- ovulation at the middle of implantation window.

6. • These molecular events resulting in blastocyst apposition with endometrial
epithelial cells is possible only because periovulatory uterine fluid is
absorbed through appearance of pinopodes.
• Pinopodes are large, rounded, smooth surfaced projections of the apical
plasma membrane of endometrial epithelial cells.
• These smooth-surfaced projections appear during the receptive phase for
blastocyst implantation in humans and represent important indicators of
normal endocrine progression, as well as uterine receptivity for blastocyst
implantation .
• Inadequate or inefficient pinopode development as in genital tuberculosis
or endometriosis leads to implantation failure.

8.  Phase of Adhesion
• Integrins (family of Cell Adhesion Molecules) play a key role in cell-to -
cell adhesion between blastocyst and endometrial epithelial cells.
• Also helps trophoblast to migrate across luminal lining, burying the
blastocyst under uterine epithelium.
• They exist in endometrium as heterodimeric α and β glycoprotein subunits.
• They have cell surface receptors both on trophoblast and on endometrium.
• Trophoblastic integrins help in attachment and migration whereas
endometrial integrins mark the boundaries of implantation window.
• 3 heterodimers of endometrial integrins exist,out of which αγβ3 is the
most significant which appears on opening day of implantation window i.e.
cycle day 19/20 and quickly disappears next day.
• Adhesion prior to invasion is mediated through osteopontin ,a ligand of
αγβ3.

9. • Other 2 integrins are less significant- α1β1 : expressed during entire period
of implantation window from ovulation to late luteal phase.
- α4β1 : expression begins with ovulation but closes with closure of
implantation window on day 24.
• Absence of integrin expression is associated with implantation failure in
endometriosis,unexplained infertility,luteal phase deficiency and
hydrosalpinges.
• Embryos/blastocysts regulate integrin expression during the phase of
endometrial adhesion.

10.  Phase of penetration and invasion
• Involves trophoblastic penetration and invasion of endometrial epithelial cells,
basement membrane, interstitial stroma (containing extracellular matrix
(ECM), stromal cells,vessels and lymphatics).
• In response to trophoblastic invasion and constant progesterone stimulation,
endometrial stromal cells and ECM undergo remodelling – known as
‘decidualisation’.
• Decidualisation includes secretory transformation of uterine glands, influx of
uterine natural killer (uNK) cells & vascular remodelling.
• Trophoblastic cells also differentiate into anchoring cytotrophoblast & highly
secretory syncytiotrophoblast,which degrade ECM by producing several
proteolytic enzymes.
• Of these enzymes, Matrix Metalloproteinase-9 (MMP-9) and Plasminogen
Activator (PA) are important and produce a ‘crater’ (implantation bed) within
the decidua.
• By day 10 of fertilization, blastocyst is completely embedded within stromal
tissue underneath the endometrial epithelium which has regrown over to cover
the site of implantation.

11. • Eventually, cytotrophoblast invades through entire endometrium and
penetrates through into the maternal vasculature  lacunar network of
choriodecidual lakes  uteroplacental circulation is established.
• Controlled and balanced trophoblastic invasion is due to delicately
regulated interaction between production of proteolytic enzymes
plasminogen activator (PA) and matrix metalloproteinase (MMP) and their
inhibitors - PA-I and Tissue Inhibitor of Matrix Metalloproteinase
(TIMP).
 Uncontrolled trophoblastic invasion  placenta accreta/increta/percreta.
 Shallow trophoblastic invasion  miscarriage,IUGR,pre-eclampsia.

12. Regulation of implantation:
 Hormones - Estrogen and progesterone.
• The levels of their receptors in endometrial stromal and epithelial cells are
also important for successful implantation.
• Deficient receptors lead to defective signalling pathway of these hormones
and receptivity factors like integrin,MECA-79,L-selectin molecules will
not be expressed leading to implantation failure.
 Prostaglandins (PGs) –increase vascular permeability during
implantation.
• Cyclo-oxygenase (COX-1 & 2) are crucial for PG synthesis.
• Endometrial expression of COX-2 relevant during adhesion phase.
• Progesterone regulates COX-2 and helps decidualisation through PG
synthesis.
• Deficiency of COX-2 and therefore of PGs causes implantation failure.
 Insulin like growth factor (IGF-1) – regulated by ovarian steroid
hormones; involved in decidualisation and blastocyst development.

13.  Transforming growth factor- β
 Epidermal growth factor
 Heparin binding epidermal growth factor
 Leukemia Inhibitory Factor (LIF)-phase of adhesion and invasion
 Interleukin-6 & 11 (IL-6,IL-11)
 Expression of cytokines & growth factors are primarily controlled by
progesterone through progesterone induced blocking factor (PIBF),
generated by T-lymphocyte & oestrogen primed endometrial cells.
 Some of these molecules are helpful for implantation or harmful-
depending on stimulus received from ovarian steroids & partly from local
environment(endometrial polyp, adenomyosis, endometriosis,
hydrosalpinx)
 2 types of responses may be generated:
 T-helper 1 (Th1) response-endometrium becomes non-receptive
 T-helper 2 (Th2) response-induces receptive endometrium

14. Role of Homeobox genes in human implantation
• HOXA genes - HOXA-10 and HOXA-11 are essential for endometrial
growth differentiation and receptivity.
• Expression of genes in endometrial epithelial and stromal cells are
mediated by oestrogen & progesterone and higher levels of expression are
present in successful implantation.
• Almost all molecular and morphological markers specific to implantation
window (chemokines, integrins, pinopodes,TGF-β, IGFBP-1,etc.) are
regulated by HOXA genes.

15. Window of implantation
• Defined as that period when uterus is receptive for implantation of the free-
lying blastocyst.
• Results from programmed sequence of action of estrogen and progesterone
on endometrium.
• usually assumed to coincide with cycle day 20-22 in a standardized cycle
of 28 days
• However, evaluation of data based on highly sensitive hCG measurements
in ART cycles estimated that the window of implantation lasts for
approximately 5 days and extends from postovulatory days 6 to10 (cycle
day 20-24 of an idealized 28 day cycle).

16. Possible mechanisms of implantation failure
• Endometrial polyp:
- Mechanical interference with sperm transport and embryo implantation
- Decreased IGFBP1 & osteopontin expression
- Low progesterone receptor expression
• Leiomyoma:
- Distorting endometrial lining
- Chronic endometrial inflammation
- Augmenting uterine contractility
- Obstruction of tubal ostia
- Abnormal vascularisation
- Decreased HOXA-10 expression
- Deranged cytokine profile

17. Possible mechanisms of implantation failure
• Endometriosis:
- Reduced expression of αγβ3 & LIF
- Lack of IL-11 receptor
- Absence of HOXA-10 & 11
- Alteration in PR-A & PR-B
- Progesterone resistance
• Hydrosalpinx:
- Mechanical interference with embryo-endometrial apposition by leaking
hydrosalpingeal fluid
- Reduced expression of αγβ3 & LIF
- Decreased HOXA-10 expression
• PCOS:
- Failure to downregulate E2 receptor during implantation window
- Increased expression of androgen receptor
- Less IGFBP-1
- Reduced expression of αγβ3 & LIF

18. Recurrent implantation failure
• ESHRE PGD consortium defined it as
Failure to achieve ‘objective evidence’ of pregnancy after transfer of 3
high-quality embryos or implantation failure with transfer of more than
or equal to 10 embryos in multiple transfers.
• ‘Objective evidence’ of pregnancy indicates observation of a stage
of intrauterine gestation which can be detected by USG.
 Primary causes of RIF
o General environmental factors:
- BMI (very low or very high)
- Smoking, Alcohol
- Thrombophilia

19. o Local environmental factors:
- Congenital uterine anomalies
- Intracavitary pathology (submucous fibroid, polyp, intrauterine adhesions)
- Adenomyosis : altered uterine peristalsis, defective decidualisation, defects
in expression of LIF, HOX-10 & integrins, increased density of
macrophages & NK cells in endometrial stroma.
- Adnexal lump (hydrosalpinx)
o Gamete and embryonic factors
o Oocyte quality
o Sperm quality
o Embryo quality
o Parental chromosomal abnormalities

20. Recurrent implantation failure
• Investigations:
-Ultrasonography
-Hysterosalpingography
-Hysteroscopy
-Combined laparoscopy and hysteroscopy
-Assessment of gametes & embryo quality
-Parental karyotype
-Sonological criteria: endometrial thickness, echogenecity, uterine and
endometrial blood flow
-Evaluation of endometrial receptivity markers during window of implantation
(endometrial sampling followed by histologic dating/electron
microscopy/immunohistochemistry, PCR & BACTEC test for genetic profile)

21. • Management
1. Treat local uterine and adnexal defects (discussed later)
2. Poor oocyte quality :
- DHEAS supplementation
- LH,GH supplementation
- Ultra-long GnRH prior to IVF in cases of advanced endometriosis
3. Poor Sperm quality:
- Prior anti-oxidant treatment to reduce sperm DNA fragmentation
- IMSI incorporated in ICSI technique
4. Embryo quality: Blastocyst transfer improves implantation rate
5. Sequential embryo transfer
6. Assisted hatching
7. Preimplantation genetic diagnosis (PGD)

22. Possible endometrial factors of RIF & suggested management

23. Hysteroscopy –role in RIF
• Intrauterine pathologies and structural uterine
abnormalities that may be responsible for the failure of
IVF can be detected and treated during hysteroscopy,
resulting in improved pregnancy rates.
• The clinical pregnancy and implantation rates
significantly increase after endometrial scratching in
same cycle in patients with good quality embryos.
• This phenomenon could be due to the injury induced
endometrial decidualization secondary to upregulation
of genes encoding for locally acting mediators.

24. Endometrial scratching
• Implantation of the embryo is still the most important
rate-limiting step in IVF,ICSI cycles.
• Even high quality embryos frequently fail to implant
resulting in an implantation rate of approximately 25–
30% per transferred embryo.
• Intentional injury to the endometrial lining, also called
‘scratching’, has been proposed as a method to improve
implantation.
• The foundation for these findings was laid early in the
20th century, when Loeb et al. showed that in guinea
pigs, mechanical irritation of the endometrium at 2–9
days after ovulation led to decidualization.

25. • Barash et al (2003) were the first to test the hypothesis that endometrial
injury in the natural cycle prior to controlled ovarian hyperstimulation
(COH) could increase the chance of pregnancy and found a two-fold
increase in live birth rate after multiple endometrial scratches compared to
no scratch.
• Since then, multiple study groups have investigated the effect of
endometrial scratching on implantation rate with differences in population,
device used (a soft plastic endometrial biopsy catheter, Karman cannula or
Novak curette), timing (luteal or follicular phase) and frequency.
• Several hypotheses supporting the positive effect of scratching on
pregnancy rates have been proposed but the exact mechanism remains
unclear.
• A Cochrane review by Nastri et al. (2015) suggests that for women
undergoing ART, an endometrial scratch in the month prior to COH
improves the chance of achieving a clinical pregnancy and live birth in
women with two or more previously failed embryo transfers, but the
evidence is of moderate quality at best.
• Endometrial scratching during diagnostic hysteroscopy seems to enhance
implantation and as well pregnancy rates in comparison to diagnostic
hysteroscopy alone.(Seval et al,2016)

26. • Multiple studies have been performed to investigate the effect of
endometrial scratching on live birth rates in women undergoing
IVF/ICSI cycles.
• Due to heterogeneity in both the method and population being
scratched, it remains unclear which group of women will benefit
from the procedure.

27. Flowchart suggesting favourable effect of local endometrial injury
(biopsy/curettage/hysteroscopy) induced inflammation on implantation
(DC-Dendritic Cells; MIP-Macrophage Inflammatory Protein; GRO-Growth Regulated Oncogene;
IL-Interleukin; NK –Natural killer)

28. Endometrial scratching

29. FIGO classification of
leiomyomas

31. Hysteroscopic myomectomy

32. Endometrial polyps
• Hysteroscopy with guided biopsy is the most common comparator for other
techniques to diagnose polyps as it offers the highest sensitivity and
specificity.
• Hysteroscopic polypectomy is effective and safe as both a diagnostic and
therapeutic intervention.
• Hysteroscopic polypectomy using electrosurgery either with a monopolar
probe or a resectoscope reduces recurrence rate compared with removal by
polypectomy forceps or microscissors.

34. Hysteroscopic polypectomy
with monopolar loop

35. Endometrial polyp with
IUCD in situ

36. Anomalies of the
uterus

37. American Fertility Society (AFS)
Classification of Mullerian duct anomalies

38. ESHRE/ESGE classification

41. Septum resection using
Collins knife

42. Lateral metroplasty : T-
shaped uterine cavity

43. Metroplasty in T-shaped uterine
cavity (fundal & lateral wall)

44. Intrauterine
adhesions/synechiae

46. Intrauterine adhesions
Clinicohysteroscopic classification
European Society of Gynaecological
Endoscopists (ESGE) classification

48. Hysteroscopic intrauterine adhesiolysis
in Asherman syndrome

49. THANK YOU