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Outlook
What can the clinician do to improve
implantation?
Carolien Boomsma is a PhD student and trainee in Obstetrics and Gynaecology in the
Department of Reproductive Medicine and Gynaecology at the University Medical Center
Utrecht, The Netherlands. Her thesis focuses on maternal and embryonic factors involved
in embryo implantation.

Dr Carolien Boomsma
CM Boomsma1,2, NS Macklon1
1
Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, The Netherlands
2
Correspondence: e-mail: [email protected]

Abstract
Implantation is a complicated process that requires the orchestration of a series of events involving both the embryo and
the endometrium. Even with the transfer of high quality embryos, implantation rates remain relatively low. The growing
tendency towards transferring fewer embryos provides further incentives to improve implantation rates. In this article, the
various clinical strategies employed to increase the chance of implantation are reviewed. Embryo transfer technique is a
critical step in assisted reproductive technology cycles. Recent studies have shown significant improvements in clinical
pregnancy rates resulting from careful embryo transfer technique, appropriate catheter type and placing for embryo transfer.
Increasingly, adjuvant pharmaceutical therapies are also being applied with the aim of improving embryo implantation.
However, the evidence for their efficacy and safety is limited. Recent evidence suggests that adoption of milder ovarian
stimulation regimens may provide a more effective clinical approach to improving implantation, since beneficial effects have
been shown for both endometrial receptivity and embryo quality.

Keywords: adjuvant therapy, embryo, implantation, IVF

Introduction IVF multiple pregnancies is to be reduced. Already faced with

frustratingly low success rates following embryo transfer,
Implantation is a complicated process that requires the IVF providers are therefore searching for strategies and
orchestration of a series of events involving both the interventions designed to increase the chance of successful
embryo and the endometrium. Even when embryos are implantation.
of high quality (determined using morphological and
chromosomal criteria), implantation rates remain around In recent years, clinicians have watched their laboratory
25−35% (European IVF-Monitoring Program, 2005). High colleagues make progress in improving embryo quality
rates of implantation failure and early pregnancy loss in and selection for transfer. Similarly, clinicians have sought
IVF are a considerable cause of frustration to both to develop clinical interventions aimed at enhancing
patients and clinicians and serve to encourage the transfer implantation rates from IVF. The competitive commercial
of multiple embryos. However, in contemporary practice, context in which IVF is usually practised has often led to the
the transfer of multiple embryos is seen less as being the early adoption of promising new interventions before clear
’solution’ to low implantation rates, but rather more as the evidence for their efficacy and safety has been established.
cause of the most important problems arising from IVF
treatment: that of multiple pregnancy (Fauser et al., 2005). In this article, the various clinical strategies which may be
The widespread adoption of single embryo transfer is employed by clinicians to increase the chance of implantation
recognized to be necessary if the morbidity associated with are reviewed.
845
 Outlook - Improving implantation - CM Boomsma & NS Macklon

Embryo transfer technique During embryo transfer, it is likely that bacteria from the cervix
may be introduced into the uterine cavity. Bacterial vaginosis
(BV) is characterized by an overgrowth of anaerobic organisms;
In recent years, the technique of embryo transfer has been
the prevalence among women undergoing IVF is approximately
shown to be an important factor in determining the outcome of
25% (Liversedge et al., 1999). There is growing evidence that
assisted reproductive technology cycles. A number of studies
the pathogenic effects of BV may not be confined to the lower
have shown that significant improvements in clinical pregnancy
genital tract. Almost half of the patients with symptomatic BV
rates can be achieved by giving due attention to embryo transfer
showed histopathological evidence of plasma cell endometritis
technique.
(Korn et al., 1995). However, there is no consensus in the
literature regarding the association of BV with the success
When difficulty in passing the catheter through the cervix is
rate of embryo implantation. Salim et al. (2002) reported a
experienced, stiff catheters make catheter placement easier, but
significantly higher pregnancy rate among women without
may be associated with more bleeding and trauma. Furthermore,
cervical colonization in the cervix versus women with bacterial
cervical manipulation may result in an increase of contractions
colonization (30.7 versus 16.3%). However, other studies have
of the uterus, which has been observed to hinder IVF outcome,
not shown this correlation (Gaudoin et al., 1999; Liversedge et
possibly by expelling embryos from the uterine cavity (Fanchin
al., 1999). At present, routine screening for BV in the hope of
et al., 1998). In a recent meta-analysis of seven randomized
improving the success of IVF treatment is not justified.
controlled trials (RCT) comparing stiff and soft embryo transfer
catheters, significantly increased pregnancy rates were observed
with the latter [odds ratio (OR) 1.34, 95% confidence intervals Adjuvant pharmaceutical therapies
(CI) 1.18–1.54] (Buckett, 2006). A further systematic review on
the effect of both the embryo transfer catheter type and volume Drug treatments adjuvant to those required for ovarian
and constitution of the transfer medium on IVF outcome is in stimulation are frequently applied in an empirical manner with
progress (Al-Inany et al., 2006). the aim of improving embryo implantation. One of the most
attractive in terms of rationale, cost and presumed safety is low
Traditionally, embryo transfer after IVF has been performed dose aspirin.
‘blindly’, with the aim of placing the embryos 1 cm below the
fundus of the uterus (Schoolcraft, 2001). However, it has been
suggested that transferring embryos lower in the uterine cavity
Aspirin
may improve implantation rates. In a prospective investigation
The rationale for the use of aspirin as an adjuvant drug in IVF
of effect of both the distance from the fundus and the relative
is based on its vasodilatation and anticoagulant properties. Its
position in the uterus of the catheter tip, significantly better
main method of action is the inhibition of cyclo-oxygenase (the
results were obtained when the catheter tip was positioned
rate-limiting enzyme in the prostaglandin synthesis pathway)
close to the middle of the endometrial cavity (Oliveira et al.,
and subsequent reduction of platelet aggregation. The aim of
2004). In this study, the absolute distance from the fundus
therapy in the context of IVF is to improve blood perfusion to the
appeared less important. However, another randomized study
ovaries and the endometrium. Kuo et al. reported a significant
revealed significantly higher implantation rates when embryos
improvement in the uterine blood perfusion (reduction of the
were deposited 1.5 or 2 cm from the fundus, compared with 1
pulsatility index of the uterine artery) in the peri-implantation
cm (Coroleu et al., 2002). In addition, a retrospective cohort
period after aspirin supplementation (Kuo et al., 1997).
study showed increased pregnancy rates when the distance
from the fundus was increased, OR 1.11 (95% CI: 1.07–
1.14); the authors suggesting that for every additional 1 mm Aspirin has been shown to be effective, either alone or in
that embryos are deposited away from the fundus, the odds combination with heparin, in the treatment of recurrent
of clinical pregnancy increased by 11% (Pope et al., 2004). miscarriage in women with antiphospholipid antibody
Moreover, increasing the distance from the fundus resulted in syndrome (APS) (Rai et al., 2002; Empson et al., 2005).
significantly lower ectopic pregnancy rates. As a result of these However, efficacy in recurrent miscarriage in women
and other similar studies, many centres have adjusted their without APS has not been proven (Di Nisio et al., 2005).
embryo transfer procedures. It has been recently postulated that In the context of IVF treatment, a RCT was performed
embryo transfer in the lower uterine segment may result in an comparing aspirin plus heparin treatment from the time of
increased risk of placenta praevia, since a six-fold higher risk of embryo transfer with placebo in 143 antiphospholipid or
placenta praevia in singleton pregnancies conceived by assisted antinuclear antibody-seropositive women with a previous
fertilization compared with naturally conceived pregnancies history of IVF implantation failure (Stern et al., 2003). No
has been reported (Romundstad et al., 2006). significant differences in implantation or pregnancy rates
were observed.
The blind nature of traditional ‘clinical touch’ embryo transfer
had led to the suggestion of a role for ultrasound in improving Randomized controlled trials investigating the use of aspirin
IVF outcomes. Following initial encouraging reports (Strickler as an empirical therapy in non-selected IVF populations have
et al., 1985), there have been numerous studies evaluating the shown conflicting results (Table 1). In a study of 374 women,
use of ultrasound-guided embryo transfer. A meta-analysis of randomized to receive either placebo or aspirin administration
four RCT comparing ultrasound-guided embryo transfer versus from ovarian stimulation onwards, no differences in ovarian
clinical touch showed a significant higher pregnancy rate and response and implantation rates were observed (Pakkila et al.,
implantation rate after ultrasound-guided transfer (1.38, 95% 2005). These results are in agreement with those of Urman et
CI 1.20–1.60) (Buckett, 2003). al. (2000). In contrast, significant improvements in ovarian
846 response and implantation rates were found by Rubinstein
 Outlook - Improving implantation - CM Boomsma & NS Macklon

Table 1. Randomized controlled trials investigating the use of aspirin as an empirical therapy in non-selected IVF
populations.

Study n Aspirin Timing of aspirin Pregnancy rate (%) P-value

dose (mg) Aspirin Placebo

Rubinstein et al., 1999 298 100 From cycle day 21 (preceding 45 28 <0.05
menstrual cycle) onwards
Urman et al., 2000 279 80 From ovarian stimulation onwards 40 43 NS
Waldenström et al., 2004 1380 75 From embryo transfer onwards 35 30 NS
Pakilla et al., 2005 374 100 From ovarian stimulation onwards 25 27 NS
Duvan et al., 2006 100 100 From embryo transfer onwards 29 40 NS

et al., who administered aspirin or a placebo from day 21 Aromatase inhibitors

of the preceding menstrual cycle in 298 women (Rubinstein
et al., 1999). A recent large RCT of 1380 women reported Aromatase inhibitors block the conversion of androstenedione
a live birth rate of 27.2% following administration of luteal and testosterone to oestriol and oestradiol respectively (Cole and
phase aspirin, versus 23.2% in the placebo group. However, Robinson, 1990). Rather than antagonizing oestrogen feedback
when adjusted for the number of embryos transferred, the activity at the hypothalamic−pituitary axis, as achieved with
difference was not statistically different (OR 1.2, 95% CI clomiphene citrate, this approach reduces the amount of
1.0–1.6) (Waldenstrom et al., 2004). Recently, a further study oestrogens synthesized, thereby increasing gonadotrophin
investigating the efficacy of aspirin administered during secretion and stimulating follicular growth (Mitwally and
the luteal phase also did not show significant differences, Casper, 2001). By preventing excessive oestradiol synthesis,
reporting a pregnancy rate of 29 versus 40% in the placebo it has been postulated that adjuvant treatment with aromatase
group (Duvan et al., 2006). A meta-analysis of 10 RCT inhibitors during gonadotrophin ovarian stimulation may result
showed no statistically significant improvement in clinical in less disruption of endometrial receptivity. One RCT has been
pregnancy rates with aspirin versus placebo or no treatment performed on women with a poor ovarian response (defined
(OR 1.18, 95% CI 0.86–1.61) (Daya, 2006). At present there by Goswami et al. as fewer than two dominant follicles). A
is insufficient evidence to support the use of aspirin outwith significantly lower total dose of FSH was required for women
the context of randomized controlled trials. using aromatase inhibitors; however, the pregnancy rates were
comparable (Goswami et al., 2004). These results are in line
Nitric oxide donors with three non-randomized trials investigating aromatase
inhibitors as an adjunct treatment in normal responders
Nitric oxide (NO) has been shown to be an important modulator (Healey et al., 2003; Mitwally and Casper, 2003, 2004). Only
of folliculogenesis (Hefler and Gregg, 2002), fertilization (Kuo a subgroup of women with polycystic ovary syndrome (PCOS)
et al., 2000), decidualization and implantation (Chwalisz and showed significantly higher pregnancy rates after addition of
Garfield, 2000). It acts as a relaxant of arterial and smooth an aromatase inhibitor (Mitwally and Casper, 2004). While of
muscle, and inhibits platelet aggregation. High resistance considerable potential value, further studies are required to
to uterine blood flow on the day of either human chorionic confirm the value and safety of aromatase inhibitors in IVF.
gonadotrophin (HCG) administration or embryo transfer is
reported to be related to a poor clinical outcome for patients Ascorbic acid
undergoing IVF (Coulam et al., 1995). These observations
suggested that uterine vasodilatation induced by a NO donor Ascorbic acid (AA) appears to be involved in normal
during IVF might improve endometrial receptivity. However, folliculogenesis (Luck et al., 1995), ovulation (Igarashi, 1977)
while initial studies suggested beneficial effects on ovarian and luteal formation and regression (Luck and Zhao, 1993). An
response and implantation (Battaglia et al., 1999), more recent imbalance of oxidative stress and antioxidant defence has been
studies suggested a detrimental effect of NO on implantation implicated in the pathogenesis of several diseases, including
(Battaglia et al., 2002; Ohl et al., 2002). Moreover, a recent recurrent abortion, unexplained infertility and defective
prospective study of women undergoing IVF for tubal or embryo development. Transient high plasma concentrations
male factor infertility reported an association between can be achieved by high dose intake of AA, which can exert
high follicular NO concentrations and advanced embryo anti-inflammatory and immunostimulant effects. These
fragmentation and implantation failure (Lee et al., 2004). effects might benefit embryo implantation. However, a RCT
Although subgroups of women may be identified who benefit investigating the effect of 1, 5 or 10 mg of AA versus a placebo
from NO donor therapy, at present the available data demand during the luteal phase in 620 women undergoing IVF showed
caution in its use, which at present should be restricted to no difference in implantation rates (Griesinger et al., 2002).
well-designed studies.
847
 Outlook - Improving implantation - CM Boomsma & NS Macklon

Prolonged progesterone embryo implantation rates; significantly higher implantation

rates were observed in women using a long GnRH agonist
An important regulator of endometrium receptivity is the protocol (RR 1.49, 95% CI 1.02–2.19) (Farhi et al., 2000). In
corpus luteum, the primary function of which is the production contrast, a recent RCT of 166 women undergoing ICSI reported
of progesterone. LH-like gonadotrophins are the primary significantly higher pregnancy and implantation rates after
stimulatory factors of corpus luteum function: firstly by means oestradiol supplementation (Lukaszuk et al., 2005). These
of the mid-cycle LH surge, secondly by the pulsatile secretion data require further substantiation, and the role of oestradiol
of pituitary LH during the luteal phase (Macklon et al., 2006). in supplementing the luteal phase after IVF remains uncertain
Following ovarian stimulation and IVF, the luteal phase is (Ghosh et al., 1994; Younis et al., 1994).
abnormal compared with the natural cycle, with characteristic
features being elevated progesterone concentrations during the Glucocorticoids
early luteal phase, followed by a dramatic and premature fall
in the unsupported mid-luteal phase (Jones Jr, 1996) (Figure Uterine receptivity is controlled by locally acting growth factors,
1). Following cessation of gonadotrophin-releasing hormone cytokines and uterine natural killer (uNK) cells (Dey et al., 2004).
(GnRH) agonist treatment for the prevention of premature It has been shown that uNK cells may have an important role
luteinization, pituitary recovery in the luteal phase takes in early implantation, since they accumulate around arteries
around 14 days (Macklon et al., 2006). The luteal phase can supplying the implantation site (Croy et al., 2002). Murine
be restored by stimulating the corpora lutea with HCG (luteal knock-out models have been used to study the effect of NK
phase support) or supplementation with progesterone. cells on fertility and pregnancy outcome. These mice achieved
pregnancies; however, an increased fetal loss has been reported
The optimal duration of progesterone administration remains (Guimond et al., 1998). This finding has not been substantiated by
to be clarified. Many centres continue with progesterone other studies (Miyazaki et al., 2002). A defect in the integrity of
supplementation throughout the first trimester of pregnancy. the number of uNK cells has also been implicated in implantation
However, the rationale for this approach is unclear. Proponents failure. Ledee-Bataille et al. reported higher numbers of NK cells
point to the uterine relaxing properties of progesterone, in endometrial biopsies from women with implantation failure
elegantly demonstrated by a reported negative correlation versus fertile controls (Ledee-Bataille et al., 2005). In women
between uterine contractility frequency and progesterone with recurrent miscarriage, prednisolone has been shown to
concentrations (Fanchin et al., 1998). Moreover, Fanchin et al. reduce the expression of uNK cells in the endometrium (Quenby
reported a significantly decreased uterine contraction frequency et al., 2005).
on the day of embryo transfer after vaginal progesterone
administration starting on the day of oocyte retrieval versus There is therefore evidence to support a possible role for
the day of embryo transfer (Fanchin et al., 2001). Secondly, glucocorticoids in improving the intrauterine environment by
progesterone has been shown to have potentially beneficial acting as immunomodulators. Studies addressing the effect of
immunomodulatory properties. Studies in mice demonstrated glucocorticoid administration to women undergoing IVF have
that progesterone administration abrogated the abortigenic been mostly small, and reveal contradictory results. An RCT
effects of stress exposure by decreasing the frequency of Th1 of 206 patients, investigating the use of glucocorticoids from
cytokines (Blois et al., 2004). Previous studies suggested that oocyte retrieval onwards, reported no differences in embryo
successful pregnancy is more likely when Th2 rather than Th1 implantation or pregnancy rates (Moffitt et al., 1995). These
cytokines are predominant (Wegmann et al., 1993). results are in line with another RCT addressing the effect of
adjuvant glucocorticoids (Mottla et al., 1996). The effect of
Although providing an appealing rationale for extended glucocorticoids on embryo implantation is currently the subject
progesterone supplementation, these studies need to be viewed of a Cochrane Systematic review (Boomsma et al., 2006). On
within the context of the endocrinology of early pregnancy the basis of the data published thus far, and considering the
after IVF. Studies of luteal function in the early pregnancy potential deleterious effects of prolonged glucocorticoid therapy
among women pregnant after IVF reported markedly raised on pregnancy with premature delivery (Empson et al., 2002),
progesterone concentrations for up to 9 weeks of gestation there is insufficient evidence to support the empirical use of
compared with spontaneous pregnancies (Costea et al., 2000) glucocorticoids to improve implantation in IVF. In certain patient
(Figure 2). It is perhaps therefore not surprising that an RCT groups, such as women with antiphospholipid syndrome, there
comparing 5 weeks versus 2 weeks of progesterone therapy may be a specific role for this therapy. Two RCT investigating
(200 mg three times daily per vaginum) from oocyte retrieval implantation rates among women with positive antinuclear,
onwards, showed no difference in outcomes (Nyboe et al., 2002). antidouble-stranded DNA, anticardiolipin antibodies and lupus
Since the multiple corpora lutea resulting after IVF produce high anticoagulant, reported significantly higher pregnancy rates
concentrations of progesterone in early pregnancy, extending after glucocorticoid administration (Ando et al.,, 1996; Geva et
therapy beyond the luteal phase is probably superfluous. al., 2000). Further research is necessary to clarify the role of
glucocorticoid therapy as an aid to implantation.
Although supplementation of progesterone is widely used to
improve implantation rates, the application of luteal oestradiol
supplementation remains controversial. A meta-analysis of three Insulin sensitizing drugs
RCT (Smitz et al., 1993; Lewin et al., 1994; Farhi et al., 2000),
using a long GnRH agonist protocol, reported no difference in The contention that insulin resistance may play a key role in the
pregnancy rates when oestrogen was added to progesterone pathogenesis of ovarian dysfunction in PCOS patients led to the
in the luteal phase (Pritts and Atwood, 2002). Only Farhi et application of insulin sensitizing drugs to improve outcomes
848 al. investigated the effect of oestradiol supplementation on from ovarian stimulation in IVF. The most studied insulin
 Outlook - Improving implantation - CM Boomsma & NS Macklon

Figure 1. Schematic representation of changes in luteal phase Figure 2. Serum progesterone concentrations (nmol/l) in
length and endocrine profile induced by ovarian stimulation normal and IVF pregnancies during the first trimester (mean
for IVF (Jones Jr, 1996). Reproduced by permission of Oxford ± SE). • Normal pregnancy; IVF pregnancy; *P < 0.05 (Costa
University Press/
Press/Human Reproduction. et al., 2000). Reproduced by permission of the International
Journal of Gynaecology and Obstetrics.

sensitizing drug in the treatment of anovulation is metformin, higher hormonal concentrations at early stages of implantation
which has been shown to be effective in achieving ovulation in is observed among GnRH agonist-treated women, which may
women with PCOS (Lord et al., 2003). However, no effect on interfere with embryonic development rather than corpus luteum
implantation rates has been reported. A meta-analysis of eight function (Hugues et al., 2006).
RCT investigating metformin in women with PCOS demonstrated
no significant differences in pregnancy rates, although the risk of Ovarian stimulation regimens
ovarian hyperstimulation syndrome (OHSS) was significantly
reduced by metformin (Costello et al., 2006). One recent RCT of The contemporary approach to ovarian stimulation in IVF
101 women with PCOS undergoing IVF, included in this meta- treatment is based on the perceived need to maximize the
analysis, demonstrated lower rates of miscarriage and OHSS in number of oocytes available for fertilization, so as to generate
the group receiving metformin (Tang et al., 2006). Caution should multiple embryos for selection and transfer. In order to obtain
be applied before insulin sensitizing drugs are prescribed in the multiple oocytes during IVF treatment, ovaries are stimulated
context of adjuvant treatment for IVF, since there is no evidence with exogenous FSH. Urinary FSH has been widely replaced by
supporting their use in a non-selected IVF population. recombinant FSH, which offers improved purity, consistency and
assured availability. However, its benefits in terms of improving
GnRH agonist pregnancy rates appear limited. For a recent review, see Macklon
et al. (2006).
It has been postulated that the LH-releasing property of a
GnRH agonist could be exploited as luteal support in non- Ovarian stimulation and the resultant supra-physiological
down-regulated cycles. Pirard et al. randomized patients to oestradiol concentrations have been shown to impact negatively on
either HCG followed by progesterone or different doses of an endometrial receptivity (Simon et al., 1995; Macklon and Fauser,
intranasal GnRH agonist. Two study groups using less frequent 2000). This may be due to advanced post-ovulatory endometrial
administration were prematurely discontinued, due to a short maturation and defective induction of progesterone receptors
luteal phase. However, the trial has shown that a regimen of three (Devroey et al., 2004). Elevated oestrogen concentrations may
intranasal administrations per day could be at least as effective increase sensitivity to progesterone action and thus lead to
as HCG followed by progesterone vaginally. Moreover, this secretory advancement. In one study of endometrial histology,
regimen is compatible with normal implantation and pregnancy advancement on the day of oocyte retrieval exceeding 3 days,
(Pirard et al., 2006). On the contrary, preliminary data from an was associated with no subsequent pregnancies (Ubaldi et al.,
RCT administrating progesterone and a GnRH agonist on the day 1997; Devroey et al., 2004). Studies of the impact of ovarian
of embryo transfer and 3 days after embryo transfer versus no stimulation on endometrial maturation several days after ovulation
GnRH agonist, did not show any beneficial effect. A trend for have shown either no effect or endometrial delay (Basir et al., 849
 Outlook - Improving implantation - CM Boomsma & NS Macklon

2001). However, the magnitude of oestrogen dose to which the regimens may aid embryo selection by increasing the chance that
endometrium is exposed has been shown to affect the duration of the transferred embryo is euploid.
the receptive phase (Kolibianakis et al.,, 2002; Ma et al., 2003).

Increasing awareness of the possible detrimental effects of

Selecting the optimal embryo,
standard ovarian stimulation regimens and their burdens on the endometrium and patient
patient, have stimulated a reassessment of the optimal approach
to ovarian stimulation for IVF (Edwards et al.,, 1996; Fauser et Improved selection of both the embryo and the optimal
al., 1999; Macklon and Fauser, 2000). Increasing knowledge of uterine environment for transfer remains the key to improving
the physiology of ovarian follicle development, together with the implantation. Embryologist colleagues have seen a number of
clinical availability of GnRH antagonists, which allow ovarian developments in recent years which may be shown to improve
stimulation to be commenced in the undisturbed menstrual outcomes. Preimplantation genetic screening for embryo
cycle, has presented the opportunity to develop novel, milder aneuploidy is being increasingly employed to aid the selection
approaches to ovarian stimulation for IVF (Fauser and Macklon, of embryos for transfer (Rubio et al., 2005; Sermon et al.,
2004; Macklon et al., 2006). 2005; Verlinsky et al., 2005). Numerous other interventions
have been developed in current laboratory practice to improve
In one RCT (Hohmann et al., 2003), it has been shown that the implantation rates, for example assisted hatching (Seif et al.,
initiation of exogenous FSH (fixed dose, 150 IU/day, GnRH 2005), the use of sequential media (Macklon et al., 2002), in-
antagonist co-treatment) as late as cycle day 5 results in a vitro maturation (Mikkelsen, 2005; von Otte, 2005) and the use
comparable clinical IVF outcome, despite a reduced duration of embryo−endometrial
endometrial co-culture (Mercader et al., 2003) in
of stimulation (and total dose of FSH given) and increased selected patients.
cancellation rates. In this study, the quality of embryos obtained
after mild stimulation was significantly greater than following Parallel to these techniques, preconceptional assessment of
the conventional long protocol. Moreover, almost all the endometrial receptivity offers the potential of correcting and
pregnancies after minimal stimulation were observed in patients optimizing receptivity prior to embryo transfer. A reliable clinical
with a relatively low oocyte yield, whereas no pregnancies were test for endometrial receptivity remains elusive, however. An
observed when a similar yield was obtained after conventional ideal molecular marker of receptivity would be obtained non-
IVF. invasively and would be highly specific and sensitive. While a
number have been proposed such as integrins, glycodelin and
Adjusting the dose of ovarian stimulation to the individual patient leukaemia inhibitory factor (Chryssikopoulos et al., 1996; Ledee-
with the aim of inducing a mild ovarian stimulation can be Bataille et al., 2002; Thomas et al., 2003), no single marker has
challenging because ovarian response varies substantially between been identified that meets these criteria. The complexity and
patients. Pharmacogenetics has emerged as an attractive tool to molecular redundancy observed in human implantation indicate
individualize FSH dosing. More clinical studies are warranted to the need to identify molecular profiles conducive to implantation.
investigate the usefulness of genotyping as a routine diagnostic In present clinical practice, assessment of endometrial appearance
test before ovarian stimulation (Greb et al., 2005). Models have and perfusion by ultrasound techniques are employed despite
been developed that enable the response dose of FSH to be poor predictive values for pregnancy (Ng et al., 2006).
determined on the basis of initial screening parameters. A model
developed by Popovic-Todorovic et al. included the number of Until high pregnancy rates can be widely achieved following
antral follicles, ovarian volume, age and smoking habits (Popovic- single embryo transfer, clinicians will limit its application to ‘good
Todorovic et al., 2003b). A RCT of an individualized dose of FSH prognosis’ patients. In recent years, a number of models have
versus a standard dose of 150 IU/day using this prediction model, been published which allow the clinician to predict the chance of
showed a higher ongoing pregnancy rate in the individual dose conception and multiple pregnancy following the transfer of one
group (Popovic-Todorovic et al., 2003a). or more embryos. Based on a number of patient-derived factors
such as age and response to stimulation, and on parameters of
The optimal number of growing follicles or oocytes retrieved in embryo quality, it is possible to identify those treatment cycles
order to maximize IVF outcome has been shown in a recent study at particular risk of leading to multiple pregnancy and for which
to be around 13 (van der Gaast et al., 2006). However, these data single embryo transfer would not reduce the chance of achieving
were derived from conventional long protocol cycles, and the a singleton pregnancy, so preventing a reduction in implantation
number is likely to be lower following mild ovarian stimulation. rates due to single embryo transfer (Hunault et al.) An increasing
The stimulation of large numbers of follicles may result in the number of IVF centres are now transferring a single embryo in
generation of poorer quality oocytes, and hence lower quality women under 37 years with at least one top quality embryo.
embryos. In a recent randomized study, preimplantation genetic
screening (PGS) was employed to investigate the chromosomal
constitution of embryos obtained after conventional ovarian Conclusions
stimulation compared with embryos obtained after mild ovarian
stimulation (Baart et al., 2005). Although more oocytes were Improving embryo implantation continues to pose a major
obtained in the conventional ovarian stimulation group, the mild challenge to clinicians. The growing trend towards transferring
group demonstrated an increased percentage of euploid embryos fewer embryos further increases the need to improve implantation
per number of oocytes retrieved. These observations support rates. Possible methods for a clinician to improve implantation
the concept of a ’natural’ selection of oocytes during follicular rates have been addressed in this review and summarized in Table
development, which may be overridden by conventional 2. The technique of embryo transfer itself has been shown to be
850 ‘maximal’ stimulation protocols. Employing mild stimulation critical in assisted reproductive technology cycles. Significant
 Outlook - Improving implantation - CM Boomsma & NS Macklon

Table 2. Ways in which a clinician could try to improve implantation rate.

What can the Method of action Empirical use in non-selected IVF population
clinician do to (presumed)
improve
implantation?

Careful embryo Minimize trauma and cervical Soft embryo transfer catheter: significantly higher
transfer technique manipulation pregnancy rates

Adjuvant pharmaceutical therapies

Aspirin Vasodilatation and anticoagulant No significant beneficial effect on pregnancy rates in a
properties non-selected IVF population
Nitric oxide donors Uterine vasodilatation No significant beneficial effect on pregnancy rates in a
non-selected IVF population. Possible detrimental
effects on embryo development
Aromatase inhibitors Reduction oestrogen synthesis: No significant beneficial effect on pregnancy rates in a
improving endometrial receptivity non-selected IVF population
Ascorbic acid Exerts anti-inflammatory and No significant beneficial effect on pregnancy rates in a
immunostimulant effects non-selected IVF population
Prolonged progesterone Luteal phase supplementation in a No significant beneficial effect on pregnancy rates in a
down-regulated cycle non-selected IVF population
Luteal oestradiol Luteal phase supplementation in a Application of luteal oestradiol supplementation
supplementation down-regulated cycle remains controversial
Glucocorticoids Immunomodulatory effect, reduction No significant beneficial effect on pregnancy rates in a
NK cell expression non-selected IVF population
Insulin sensitizing drugs Minimizing insulin resistance No significant beneficial effect on pregnancy rates, but
it may reduce the miscarriage and OHSS rate in women
with PCOS; empirical use in a non-selected IVF
population has not been investigated
GnRH agonist LH-releasing properties Can possibly be exploited as luteal support: no
beneficial effect on implantation rates described

Ovarian stimulation
Mild stimulation regimens Improvement of endometrial Comparable IVF outcomes, despite fewer oocytes
receptivity and increased percentage
of euploid embryos, despite
fewer embryos
Prediction of optimal Optimal stimulation level Prediction models may have a role. In the future,
starting dose FSH in the pharmacogenetics is likely to become important
individual patient

Selecting optimal embryo, endometrium and patient

Preimplantation genetic Selection of euploid embryos No RCT in a non-selected IVF population have been
screening published yet
Marker for endometrial Correcting and optimizing receptivity A reliable test remains elusive
receptivity prior to embryo transfer
Selecting patients for SET Identification of patients in which No prospective analysis of prediction models has yet
SET does not reduce the chance of been performed
achieving a singleton pregnancy

851
 Outlook - Improving implantation - CM Boomsma & NS Macklon

improvements in clinical pregnancy rate can be achieved by Baart EB, Van Opstal D, Eijkemans MJ et al. 2005 Does the
giving due attention to the type of catheter used and embryo magnitude of ovarian stimulation for IVF affect chromosomal
transfer position. In contrast, although adjuvant pharmaceutical competence of embryos as assessed by PGS? 21st Annual meeting
of the ESHRE. Human Reproduction 0–246, i 91−i 92.
interventions are increasingly being applied with the aim of
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Journal of Social Gynecological Investigation, in press.
Despite numerous new interventions to improve the success Boxmeer JC, Brouns MM, Lindemans J et al. 2005 Folic acid
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