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

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 < 10th centile, when compared with no treatment for women considered at increased risk of placental dysfunction.

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 < 10th %, placental abruption, or IUFD >20 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) (p=0.01). Decrease of 54%.

RR reductions with LMWH included any PE, severe PE, SGA <10th, SGA <5th, preterm delivery <37 weeks and preterm delivery <34 weeks.

IVF failure

Recurrent implantation failure Growth hormone (non significant=NS)Androgen supplementation- NSSteroids (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.

Effect of heparion on trophoblast invasion

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.

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.

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.

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.

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.

Rimon E. and Kupferminc M. In press

LT- APS treated with LMWH and normal implantationRT-APS not treated with LMWH and abnormal implantation

To determine the effect and safety of thromboprophylaxis using LMWH in women with recurrent IVF-ET failure and thrombophilia.

83 women with history of >3 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.

Qublan et al., LMWH in the treatment of recurrent IVF-ET

failure and thrombophilia: a prospective randomized placebo-controlled trial. 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 < 0.001 and p < 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 < 0.05). The abortion rate was significantly higher in the placebo-treated group compared to the LMWH group (p < 0.05).

LMWH in the treatment of recurrent IVF-ET failure and

thrombophilia: a prospective randomized placebo-controlled trial. Qublan et al., Hum Fertil 2008

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 (> 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.

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 (p=0.01).

150 women with > 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.

Overall outcomes.LMWH, low molecular weight heparin.

Urman B et al. Hum. Reprod. 2009;24:1640-1647

34.7%

26.7%

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

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

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 > 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%.

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 > 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%

Noci et al., effect of daltaparin sodium

administration on IVF outcome in non-thrombophilic young women. Reprod Biomed Online 2011

172 women < 40 years, negative for thrombophilias, who underwent their first IVF cycle, were randomly allocated to treatment (n=86) 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.

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).

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.

LMWH in women with repeated implantaion failure.

Lodigiani et al. Women Health 2011.

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.

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.

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.

•

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.

Heparin for assisted reproduction (Review)

Cochrane Aug 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.

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.

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.

Adjunct low-molecular-weight heparin to improve live birth rate after recurrent implantation failure: a systematic

review and meta-analysis. Human Reproduction update 2013

Thank you

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.

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, 95%CI 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).

219 women women with 2 >chemical 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; p=0.03.

Subgroup of 95 with 3 > 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.

Kupferminc. Personal Data