Does Flushing the Uterine Cavity With Follicular Fluid After Ovum Pick-up Improve Implantation Rates in ICSI Cycles?
Condition: Intra-cytoplasmic Sperm Injection Outcome
MeSH terms: Flushing
Study type: Interventional
Phase: Phase 1

Summary: 
      Background:

      Traditionally during ovum pick-up in ICSI, we aspirate the follicles for oocyte retrieval but
      unfortunately we don't make use of the follicular fluid (FF) and we discard it in spite of
      the fact that this does not happen in nature. The fallopian tube picks-up the FF with the
      oocyte during ovulation. As this fluid contains stem cell factor and C-Kit receptor
      responsible for implantation and IGF responsible for endometrial growth and TGF that improves
      implantation. That's why flushing the endometrial cavity with FF after ovum pick-up might
      improve endometrial receptivity and implantation rates; the limiting step in ICSI.

      Patients and Methods:

      100 patients attending kasr El-Aini IVF center preparing for ICSI cycles are randomized into
      two groups. In the study group, flushing the endometrial cavity with 2ml of clear follicular
      fluid surrounding mature oocytes through an IUI catheter is done after ovum pick-up While in
      the control group, no flushing of the endometrial cavity with FF is done. The implantation
      rates and pregnancy rates in both groups will be assessed.
    

Detailed description: 
      Introduction:

      Looking at the process of IVF, we found that we only make use of the ovum and sperm and we
      neglect completely the valuable effect of the follicular fluid which is currently attracting
      a lot of attention. Several studies revealed a pivotal role played by this fluid in the
      process of fertilization and implantation as it is rich in growth factors as stem cell
      factor, transforming growth factor and insulin growth factor and cytokines (1,2).

      Macciò study confirmed that follicular fluid (FF) contains factors that induce
      immunosuppression and explained that the immunosuppressive activity of FF is mediated by the
      specific inhibition of the production of IL-1 alpha and IL-2 and by the decreased expression
      of the CD25 (3).

      During ovum pick-up, we aspirate all the FF and throw it away after ovum retrieval. This
      fluid normally enters the fallopian tubes while picking the ovum during ovulation in natural
      cycles and it reaches the uterine cavity as well and several studies suggested that it might
      have a crucial role in modifying uterine receptivity preparing the endometrium for the
      fertilized ovum arriving after 3 days as the TGF controls apoptosis, the IGF improves
      endometrial thickness and the immunosuppressive activity of the FF paves the way for the
      embryo to implant in the uterine cavity (4,5).

      Actually Hunter study in 2007, provided circumstantial evidence for entry of follicular fluid
      into the Fallopian tubes, especially close to the time of ovulation, with the suggestion that
      such entry could modify the nature of endosalpingeal secretion and transudation. Thereafter,
      the spectrum of gonadal hormones in follicular fluid could be influencing uterine tissues in
      a local manner (5).

      At the same time, it is a well known fact that implantation is the limiting step in IVF
      success , actually almost all IVF cycles succeed in offering fertilized ova giving rise to
      embryos at the different stages of development but unfortunately when we transfer them to the
      uterine cavity, 60% fail to implant.

      Implantation is a complex initial step in the establishment of a successful pregnancy.
      Although embryo quality is an important determinant of implantation, temporally co-ordinated
      differentiation of endometrial cells to attain uterine receptivity and a synchronized
      dialogue between maternal and embryonic tissues are crucial. Optimizing endometrial
      receptivity in fertility treatment will improve success rate.

      Several growth factors and cytokines appear to be involved in the process of implantation.
      Stem cell factor and its receptor c-kit regulate the progression and survival of germ cells
      and play an important role in follicular development. It is present in the follicular fluid
      however little information was available on the role of stem cell factor and its receptor in
      the process of blastocyst implantation. It was not until Mitsunari examined the expression of
      stem cell factor and its receptor in mouse embryos and in the stromal and epithelial cells of
      the uterine endometrium by reverse transcription -polymerase chain reaction . He illustrated
      that stem cell factor derived from endometrial cells and the implanting embryo exerts
      paracrine and autocrine action on the process of implantation by stimulating trophoblast
      outgrowth through its receptor c-kit (6).

      Neglecting the importance of the follicular fluid and throwing it away during the process of
      IVF is actually a deviation from what happens in nature where the fallopian tube is
      intelligent enough to appreciate the value of this fluid and pick it up with the ovum.

      That is why in this study, we want to mimic natural cycles and explore the benefits of
      flushing the uterine cavity with follicular fluid after ovum pick-up in improving
      implantation rates in ICSI cycles.

      Materials and methods:

      100 patients attending kasr El-Ainey IVF center preparing for ICSI cycles will be randomized
      into two groups.

      In this prospective interventional study, the patients of both groups will receive the same
      induction protocol for controlled ovarian hyperstimulation which is the long protocol, our
      standard protocol in the center. Initial suppression of ovarian function with gonadotrophin
      releasing hormone agonist will start on day 21 of the preceeding cycle. Human menopausal
      gonadotrophin induction will start after confirmed ovarian down regulation by both laboratory
      investigations and ultrasound by daily intramuscular injection of 150-300 IU (Merional, IBSA)
      until at least 3 follicles reach 18 mm and serum estradiol level lies between 1000-4000 then
      10000 IU, HCG is given.

      Ovum pick-up is scheduled 35 hours later, where each follicle is aspirated in a separate tube
      and will be examined by the embryologist separately where:

        -  The follicular fluid from empty follicles will be discarded, only the FF from follicles
           where mature oocytes were retrieved will be used.

        -  The follicular fluid contaminated with blood will be discarded and would not be used,
           only the clear FF will be used.

        -  No flushing was used after oocyte aspiration in order not to interfere with the
           concentration of growth factors in the FF .

      After explaining the procedure and taking informed consent from the patients:

      2ml of clear follicular fluid will be injected in the uterine cavity to flush the endometrium
      through an IUI catheter after performing mock transfer in the study group.

      While, in the control group, no flushing of the endometrial cavity with FF is done.

      In both groups, embryo transfer will be carried out 2-3 days later according to the condition
      of the embryos and pregnancy test will be carried out 14 days later.

      The protocol was approved by the review board at kasr el-Aini hospital; IVF center at Cairo
      university.
    

Intervention name(s): Follicular fluid
Intervention type(s): Biological
Intervention description(s): The intervention is flushing the uterine cavity with 2 ml of clear follicular fluid surrounding mature oocytes after ovum pick-up through an IUI catheter
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Follicular Fluid; uterine cavity; Implantation rates; ICSI