Can we prevent miscarriage ? Can we reduce its incidence? Can progesterone help in this? let's see

1. HOW TO REDUCE MISCARRIAGE ?
Company Name
PRESENTED BY
HESHAM AL-INANY M.D, PHD

2. AGENDA
2
3
4
INTRODUCTION
1
Progesterone
TAKE HOME MESSAGE
NIPGT

3. Concept
• Prevention is better than Cure

4. Prevention vs Reduction
• Can we prevent Miscarriage ?
• Can we reduce Miscarriage rate?

5. Introduction
Miscarriage: Sporadic – Recurrent
ACOG 2015: Two or more :
Because the risk of a recurrent loss is fairly
high after 2 losses (26%), we have to start
work-up after 2 losses.
Specifically with AMA

6. MATERNAL AGE
Maternal age Clinical Preclinical
< 20 y 12.2 % 20 %
20-24 14.3 29
25-29 13.7 30
30-34 15.5 35
35-39 18.7 40
40-44 33.8 45
> 44 53.8 65
Human Reproduction
12:387,2012

7. Etiology
Even an extensive workup will fail to find a
recognizable cause in up to 50% of cases
Mostly attributed to : Immune system
Aneuploidy
So how to reduce ?

8. AGENDA
2
3
4
INTRODUCTION
1
Immunomodulation
CONCLUSION AND TAKE HOME MESSAGE
NIPGT

9. PROGESTERONE
Progesterone (ng/ml)
Progesterone
Weeks of pregnancy
4 8 12 14 16 20 24 28 32 36 40
100.0
50.0
10.0
5.0
1.0
0.5
0.1
0.05
Plasma levels of Progesterone in pregnancy are of
125-200 ng/ml (vs 11 ng/ml of luteal phase)
Decrease of pregestrone plasma levels is associated with triggering
of labor in most animal species

10. PROGESTERONE: IMMUNOLOGIC
PROPERTIES
 CITOCHINE TH2 (IL-3, IL-4, IL-10…)
 PIBF production by TH2 Lymphocytes
Direct inhibition of NK cells
 LIF production by Lymphocyte
 PP14 endometrial production
 T-Suppressor (CD4)/T-Cytotoxic (CD8) RATIO
CELL-MEDIATED
RESPONSE
HUMORAL MEDIATED
RESPONSE
Lymphocyte B, Plasma cells
Lymphocyte T, NK cells

11. Progesterone
Arachidonic Acid
Prostaglandins
Immunomodulation
PROGESTERONE
INDUCED
BLOCKING FACTOR
“PIBF”
Phospholipase A2
Phospholipase C
CYTOKINE
BALANCE
IL -2; 12 ; IFN gamma; IFN alfa
IL - 4; 5; 10
NK cells
Activity

12. Additional Role of Progesterone
2.0
2.5
3.0
3.5
4.0
4.5
Day 15 Day 16 Day 17 Day 18 Day 19 Day 20
UC Frequency/min
0%
5%
10%
15%
20%
25%
<3.0 3.1-4.0 4.1-5.0 >5.0
(Fanchin et al, 1998)
(De Ziegler et al, 1996)
UC/min
UC = uterine contractions.

14. Luteal Phase in ART Cycles
• Iatrogenic luteal phase defect due to
supraphysiological steroid levels in
stimulated cycles
Fatemi et al. Hum Reprod Update. 2007

15. Rationale
1. Aspiration of granulosa cells at egg retrieval
2. Achievement of supraphysiologic levels of
E2 with current stimulation protocols

16. Cochrane Review 2011
Pregnancy rates are significantly reduced in
GnRHa ovarian stimulation without luteal phase support

17. WAYS OF ADMINISTRATION OF
PROGESTERONE
INTRAMUSCULAR
?
TRANSVAGINAL
?
ORAL
?

18. Convenience and Side Effects
Intramuscular
pain
Local Reaction,
Severe Allergic Reaction
(rare)
Vaginal
irritation, and soreness

19. LOTUS STUDY
A double-blind, double-dummy, randomized, multicenter,
multinational study comparing the efficacy, safety and tolerability
of oral dydrogesterone
30 mg versus MVP capsules 600 mg daily for luteal support in
IVF
• 38 sites, in 7 countries: Austria, Belgium, Finland, Germany,
Israel, Russia, Spain

20. 1066 Participants
Screening
and
enrolment
Day–14
Days 2–7
Embryotransfer
Post-treatment
safety
evaluationevery
2 months
Follow-up
30 days or6
months
after
deliverya
Oral dydrogesterone 30 mg (n=520)
MVP 600 mg (n=511)
Day–1
Week 12 ofgestation
End of treatment
OR and
treatment start
Week 10 of treatment
Ultrasound performed
Day 1
Weeks of Gestation
Week 4 Week 8
Pregnancy test
(serum β hCG and urine striptest)
Weeks of Treatment

21. PATIENT FLOW
Assessed for eligibility (n=1143)
Excluded (n=112)
• Screening failures (n=104)
• Terminated prematurely (n=8)
Full analysis sample (n=497)
• Excluded from analysis:
• Embryo transfer not successful (n=22)
• Did not receive allocated intervention (n=1)
Per protocol sample (n=492)
• Excluded from analysis:
• Excluded from the full analysis sample (n=23)
• Major protocol deviations unrelated to treatment (n=5)
Lost to follow-up (n=5)
Discontinued (n=342)
Allocated to oral DYD (n=520)
• Received allocated intervention(n=519)
– Safety Sample
• Did not receive allocated intervention (n=1)
Lost to follow-up(n=5)
Discontinued (n=364)
Allocated to MVP(n=511)
• Received allocated intervention (n=510)
– Safety Sample
• Did not receive allocated intervention (n=1)
Full analysis sample (n=477)
• Excluded from analysis:
• Embryo transfer not successful (n=33)
• Did not receive allocated intervention (n=1)
Per protocol sample (n=475)
• Excluded from analysis:
• Excluded from the full analysis sample (n=34)
• Major protocol deviations unrelated to treatment (n=2)
Randomized (n=1031)

22. Results
aPercentages are based on the number of subjects in the full analysis sample with data available. BMI values were calculated from the following populations:
bn=496; cn=476; dn=972
Copyright ClearanceCenter, Inc.
Oral DYD
(n=497)
MVP
(n=477)
Total population
(N=974)
Mean age, years (SD) 32.5 (4.5) 32.5 (4.4) 32.5 (4.4)
Age category, n (%)a
≤35 years of age 352 (70.8) 348 (73.0) 700 (71.9)
>35 years of age 145 (29.2) 129 (27.0) 274 (28.1)
Race or ethnicity, n (%)a
Caucasian 485 (97.6) 453 (95.0) 938 (96.3)
Black or African American 9 (1.8) 14 (2.9) 23 (2.4)
Asian 4 (0.8) 9 (1.9) 13 (1.3)
Other 0 (0.0) 2 (0.4) 2 (0.2)
Mean BMI, kg/m2 (SD) 23.3 (3.1)b 23.2 (3.1)c 23.2 (3.1)d
Prior treatment, n (%)a 30 (6.0) 25 (5.2) 55 (5.6)

23. OUTCOMES
Oral DYD
(30 mg)
MVP
(600 mg)
Total
population
Number of subjects who
underwent embryo transfer, n
497 477 974
Subjects who underwent embryo
transfer after ICSI, n (%)a
368 (74.0) 338 (70.9) 706 (72.5)
Day of embryo transfer after
oocyte retrieval, n (%)a
<5 days 350 (70.4) 328 (68.8) 678 (69.6)
≥5 days 147 (29.6) 149 (31.2) 296 (30.4)
Number of embryos transferred, n (%)a
1 212 (42.7) 217 (45.5) 429 (44.1)
2 278 (55.9) 252 (52.8) 530 (54.4)
>2 7 (1.4) 8 (1.7) 15 (1.5)
Number of subjects who had at least
one newborn, n (%)a
172 (34.6) 142 (29.8) 314 (32.2)

24. NNT
Pregnan
cy
rate
% (n/N) Difference in
pregnancyratea
(OralDYD–
MVP)
95% CI
Oral DYD MVP
FAS
37.6
(187/497)
33.1
(158/477)
4.7 –1.2, 10.6
PPS
37.6
(185/492)
33.1
(157/475)
4.7 –1.2, 10.6
NNT with oral DYD to obtain a benefit versus MVP
would be 22
Non-inferiority
margin
Favors MVP
-15 -10 -5 0 5 10
Favors oral DYD
15

25. LBR
Rates of live births were similar between the two treatment groups, withnumerical
differences in favor of oral DYD
In the FAS, the NNT with oral DYD to obtain a benefit versus MVP would be 21 (95%CI
for absolute risk reduction of NNT [benefit] 9.3 to NNT [harm]125])
Live
birt
h
rate
% (n/N) Difference in
pregnancyrate
(OralDYD–
MVP)
95% CI
Oral DYD MVP
FAS
34.6
(172/497)
29.8
(142/477)
4.9 –0.8, 10.7
PPS
34.6
(170/492)
29.9
(142/475)
4.7 –1.1, 10.5
Non-inferiority
margin
Favors MVP
-15 -10 -5 0 5 10
Favors oralDYD
15

26. 2019: PROMISE Trial: RPL

27. Cochrane 2019

28. 2020: PRISM Trial :
Threatened abortion
live birth rate was 72% (98/137) with progesterone vs 57%
(85/148) with placebo (RR, 1.28; 95% CI, 1.08–1.51; P=.004
NNT = 8

29. 2021 : Cost analysis
• An average cost of £204 per pregnancy,
the use of progesterone was cost-effective
in reducing miscarriage rate.

30. 75%
• Consultants in UK prescribe progesterone
for reducing miscarriage rate

31. AGENDA
2
3
4
INTRODUCTION
1
Immunomodulation
TAKE HOME MESSAGE
NIPGT

32. Aneuploidy
 Preimplantation genetic screening
(PGS) is widely used to select in vitro-
fertilized embryos free of
chromosomal abnormalities and to
improve the clinical outcome of in
vitro fertilization (IVF) (Xu et al. 2016)
 However PGS is invasive ,
requires specialized skills, suffers
from false +ve and –ve. (Huang et
al., 2019)

33. PGT
Braude, P., Pickering, S., Flinter, F. et al.
Preimplantation genetic diagnosis. Nat Rev
Genet 3, 941–953 (2002).
https://doi.org/10.1038/nrg953

34. NIPGT
 NIPGT is a less-invasive technique
to assess the genetic
and chromosomal defects.
 The goal of the NIPGT is to utilize
the cell free embryonic DNA
(cfeDNA) in assessment
of chromosomal status of the
embryo (NIPGT-A).
Kuznyetsov et al., 2019 & Cimadomo et al., 2016)

35. Methods for NIPGT
Embryo spent
culture medium
Blastoceol fluid
Combined Embryo
spent culture
medium +
blastoceol fluid
CELL FREE
EMBRYONIC
DNA
Palini et al., 2013, Tobler et al.,
2015 & Gianaroli et al., 2014
(Assou et al. 2014, Xu et al., 2016
Blendares et AL., 2018)al
Jiao et al., 2019, Li et al.,2018​​

36. Combined Embryo spent culture medium +
blastoceol fluid
Kuznyetsov et al. (2018)
N47 Day 4-6 embryos (28thawed- 19 fresh)

37. Combined Embryo spent culture medium +
blastoceol fluid
 Huang et al. (2019) compared the results of three
genetic analyzes: invasive PGT-A vs NIPGT and total
DNA obtained from the blastocysts.
 False positive results were significantly less common in
NIPGT (20%) than PGT-A (50%) when both were
compared with total blastocyst screening as gold
standard

38. Should We Offer IVF/NIPGT to Couples
with Unexplained RPL?
Rationale Evidence
Improve subsequent live birth rate No evidence to support using IVF for this purpose
Shorten the time to conceive To date, IVF has not shown any benefit
Improve embryo quality by sperm selection, PGT-A
and morphological evaluation
Might improve pregnancy outcome but powered
studies needed
Improving implantation Evidence lacking, so can’t be recommended.
Improve synchrony between endometrium and
embryo
Might be justified in order to avoid non optimal
timing of intercourse or conception.
• Only if AMA

39. TAKE HOME MESSAGE
Ø Progesterone Can help to prevent
miscarriage
Ø NIPGT in recurrent miscarriage in AMA is
yet to be tested.

40. 98
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