O-031 Tacrolimus treatment significantly improved IVF outcomes with euploid embryo transfer in women with repeated implantation failures (RIF) and elevated T helper (Th)1/Th2 cell ratios
Authors: Nakagawa K , Kwak-Kim J , Horikawa T , Kuroda K , Takamizawa S , Maruyama T , Sugiyama R , Yamaguchi K 
Published: July 2024

Abstract

Study question
Dose tacrolimus improve implantation rate for RIF women showing elevated T helper (Th)1/Th2 cell ratios, particularly those undergoing IVF/ET with euploid blastocysts?

Summary answer
Tacrolimus improved the implantation rate in RIF women with elevated Th1/Th2 cell ratios undergoing IVF/ET using euploid blastocysts.

What is known already
The peripheral blood Th1 and Th2 cells determine immune inflammatory responses at the maternal-fetal interface. Previously, we reported that about 40% of women with RIF (≥4) had elevated Th1/Th2 cell ratios (≥10.3). The pregnancy rate was significantly improved when they were treated with tacrolimus, an immunosuppressive agent [AJRI 2015]. However, genetic embryonic concerns of RIF could not be ruled out since not all transferred embryos were genetically screened. Recently, we reported an adjusted cut-off value of the Th1/Th2 cell ratios (≥11.8) [AJRI 2021] for women with RIF based on the retrospective analysis. However, the prospective study has not been performed.

Study design, size, duration
A prospective cohort study was performed, including 569 infertile women with more than 4 times of RIF. The study participants received ET with euploid blastocysts from September 2020 to November 2021. All transferred blastocysts were confirmed as euploid or low-frequency mosaic by preimplantation genetic testing for aneuploidy, and the endometrial preparation for ET was made by using either hormone replacement cycle or natural ovulatory cycle.

Participants/materials, setting, methods
Before ET, all participants were measured for their peripheral blood Th1/Th2 (CD4+IFN-γ+/ CD4+IL-4+) cell ratios in the secretory phase. Women who had elevated Th1/Th2 cell ratios (≥10.3) received tacrolimus (2-4 mg daily). Tacrolimus was started 2 days before ET, and the hCG and gestational sac (GS) rates were calculated in women with or without tacrolimus.

Main results and the role of chance
Of 569 participants, 174 (30.6%) women showed elevated Th/Th2 cell ratios (≥10.3), whereas the remaining 395 women served as control (Control group). Among 174 women, 148 women received tacrolimus (Tac group), while 26 did not receive tacrolimus (no-Tac group). The hCG and GS rates of the Tac group were 73.0% and 64.2%, respectively, similar to the no-Tac group (69.2% and 57.7%, respectively, P=NS). Meanwhile the hCG and GS rates of the control group were 70.6% and 60.0%, respectively (P=NS).
When the Th1/Th2 cell ratio cut-off value was set to ≥ 11.8, 123 women of the 569 participants (21.6%) had elevated Th1/Th2 cell ratios (≥11.8). Among them, 112 received tacrolimus (Tac2 group), and 11 did not tacrolimus (no-Tac2 group). The remaining 410 women were as a control group (Control2 group). The GS rate of the Tac2 group was 67.0%, which was significantly higher than that of the no-Tac group (36.3%, p &lt; 0.05), while the GS rate of the Control2 group was 60.5% (P=NS, vs Control2 group).
Tacrolimus dosing data was as follows; 11.8 or more but less than 15.8 of Th1/Th2 cell ratios were needed for 2 mg of tacrolimus daily, and 15.8 pr more was needed for 3 mg of tacrolimus.

Limitations, reasons for caution
The study was a controlled trial with a limited number of study population. Additionally, the endometrial changes or peripheral immune responses after tacrolimus were not evaluated thoroughly. Further study is needed for the tacrolimus effect on systematic immune responses and local endometrial immune milieu.

Wider implications of the findings
Before ET, screening for increased Th1/Th2 ratios (Cut-off value ≥11.8) may significantly improve IVF outcomes by selecting proper candidates for tacrolimus treatment and detecting the proper tacrolimus doses. Notably, a significant proportion of women with RIF have additional implantation failures, even with euploid embryos, when immune-inflammatory conditions were not controlled.

Trial registration number
not applicable