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Signal of the endometrium ready
for implanation: genetic clinical
diagnosis
Xavier Santamaria MD; PhD.Director Asherman’s Project, iGenomix
Research Associate, Ob/Gyn Department VHIR
Ob/Gyn IVI Barcelona
Xavier Santamaria
Director of Asherman’s Project, Igenomix
Disclosure
ART remains inefficient
✓Globally, live birth rates in ART range between 25% and 30% per
initiated cycle
✓ The most fundamental reason why IVF treatments are not successful is
because transfer of good quality embryos or even euploid embryos
into the endometrial cavity does not lead to pregnancy.
Malizia B et al., N Engl J Med. 2009
Adamson et al., Fertil Steril. 2011
74 % of failed IVF cycles = failed implantation
IVF results, The Netherlands, 2010
92%
81%
27% (37% cum)
27% (37% cum)
Total 16,898 started cycles
48% ICSI
Cum = fresh+froozen ET
91% singleton pregnancies
The contribution of the embryonic and endometrial factor
Embryo Aneuploidies
Drosophila 0.01 %
Mouse 0.01 %
Human 20 – 100 %
Implantation Rate (IR)
Natural cycle 35 %
Euploid embryos 60 %
Rodents 95 %
Rabbits 96%
(Rubio et al. RCT Fertil Steril 2017)
The main difference between humans and rodents lies in
The endometrial/decidual control in human implantation
versus
The embryo control in rodent implantation (embryonic diapause)
Endometrial
Microbiota
Moreno et, al. AJOG 2016
Moreno et, al. AJOG 2018
Endometrial Receptivity
Diaz-Gimeno et, al. F&S 2011
Ruiz-Alonso et, al. F&S 2013
Garrido-Gomez et. al, HR 2014
Von Grothusen et. al, HR 2018
Wang W. et al. Nature Medicine.
2019 in press
Simon C. et al. HR 2019 in press
Decidualization Decidualization
Garrido-Gomez et. al, JCEM 2011
Garrido-Gomez et. al, Development 2017
Garrido-Gomez et. Al, PNAS 2017
Vilella et, al. Development 2015
Balaguer et, al. MHR 2018
Balaguer et, al. AJOG 2019
The Maternal Contribution
Materno-Embryonic Crosstalk
Endometrial
microbiota
Endometrial
receptivity
Decidualization
Materno-embryonic crosstalk
The Maternal Contribution
Endometrial receptivity
Plasma membrane transformation
Anatomical medicine: dating the endometrium
300 protocols reviewed
40 correlated with basal body temperature
13 were photographed
8 major histologic criteria were described
The most cited paper ever in Obst/Gyn.
RCTs: Murray et al., Fertil Steril 2004; Coutifaris, et al. Fertil Steril 2004
2,630 times cited
Endometrial thickness and pregnancy rates after IVF: a systematic review and meta-analysis
Kasiu et al., Hum Reprod Update, 2014
The use of EMT as a tool to decide on cycle cancellation, freezing of all embryos or
refraining from further IVF treatment seems not to be justified based on the current
meta-analysis
Endometrial Thickness (EMT) is not diagnostic of endometrial receptivity
Riesewijk et al., 2003 (HG-U133 2.0) WOI
Ponnapalam et al., 2004 (Home-made array) menstrual cycle
Talbi et al., 2005 (HG-U133 2.0) menstrual cycle
WOI
Molecular medicine: human endometrial transcriptome
Díaz-Gimeno et al., Fertil Steril 2011
Receptive
ERA classifies the molecular receptivity status of the endometrium
Post-ReceptivePre-Receptive
The symphony of syncronization
Progesterone
Epithelial
PR
P P+1 P+2 P+3 P+4 P+5 P+6 P+7 P+8 P+9
Personalized embryo transfer (pET) as a treatment for RIF of endometrial origen
P+5P+3 P+7
LH+7LH+5 LH+9
ETpET
How many lines of evidence lead to the conclusion
Essential protection against flawed ideas is triangulation.
This is the strategic use of multiple approaches to address one question.
Each approach has its own unrelated assumptions, strengths and weaknesses.
Munafo & Davey Nature 553, 399-401 (2018)
Single cell analysis from endometrial biopsy
Stromal
cells
Epithelial
cells
Single cell separation
Wash cells with
DMEM medium
Endometrial biopsy
Single-cell isolation
500 bp
Wanxin et al., bioRxiv online Jun. 19, 2018;
doi: http://dx.doi.org/10.1101/350538 Nature Medicine submitted.
Data: 2,149 cells from 19 healthy ovum donors throughout their natural menstrual cycle.
Endometrial Cell Types at Transcriptome Level
log2 (rpm+1)
log2
(FC)
4.5
7.5
Cellular component (FDR)
Biological process (FDR)113 + 6 single cells analyzed per donor:
• 48.23 % epithelial cells (2.19% ciliated and 46.04%
non-ciliated)
• 43.76% stromal fibroblasts,
• 1.44% endothelial,
• 5.91% lymphocytes
• 0.65% macrophages
Temporal Transcriptome Dynamics
mid-secearly-seclate-promenstrual early-pro late-sec
WOI
Un
cili
ate
d
ep
ith
elia
log2 (rpm+1)
Decidualization
mid-secearly-seclate-promenstrual early-pro late-sec
Str
om
al
fib
rob
last
s
CLINICAL WORK-CONNEGATIVE HYPOTHESYS
CLINICAL WORK-CON
Control Group (n=11)
LH+7
LH+2
LH+7
Day 3 – 9 of cycle
Treated Group (n=7)
LH+7
LH+2
Mifepristone
Von Grothusen et al., 2018
What if ET is performed in a Non-Receptive WOI diagnosed by ERA?
Clinical Outcome NR (52) R (205)
IR First attempt 13% (12/90) 45% (161/355)
IR Total attempts 10% (17/174) 41% (182/441)
PR First attempt 23% (12/52) 60% (123/205)
PR Total attempts 17% (17/100) 55% (140/253)
OPR First attempt 0% (0/12) 74% (91/123)
OPR Total attempts 0% (0/100) 74% (103/140)
Clinical efficiency Positive (52) Negative (205)
True 40 123
False 12 82
Sensitivity (TP/TP+FN) 0.33
Specificity (TN/TN+FP) 0.91
PPV (TP/TP+FP) 0.77
NPV (TN/TN+FN) 0.60
P-466 Ruiz-Alonso et al, Clinical efficiency of embryo transfer performed in receptive vs non-receptive endometrium
diagnosed by the endometrial receptivity array (ERA) (70th ASRM Annual Meeting, Honolulu, Hawaii. 2014)
CLINICAL WORK-PRO
Editorial, Expert Opinion
Case Series, Case Report
Case-Control Studies
Cohort Studies
RandomizedControlled Trial
Meta-Analysis
ERA Publications
2014 Clinical Management of Endometrial Receptivity Semin Reprod Med. 32(5):410-4
2014Timing the window of implantation by nucleolar channel system prevalence matches the accuracy of the
endometrial receptivity arrayFertility and Sterility. 102(5):1477-81
2015 Human Endometrial Transcriptomics: Implications for Embryonic ImplantationCold Spring Harb Perspect Med.
5(7):a022996
2015 Understanding and improving endometrial receptivityCurrent Opinion in Obstetrics &
Gynecology. 27(3):187-92
2015 Is endometrial receptivity transcriptomics affected in women with endometriosis? A pilot studyReproductive BioMedicine Online.
31(5):647-54
2016 Diagnosis of endometrial-factor infertility: current approaches and new avenues for research Geburtshilfe Frauenheilkd.76(6): 699-703
2017Does an increased body mass index affect endometrial gene expression patterns in infertile patients? A functional
genomics analysisFertility and Sterility.107(3):740-748.e2
2017 Endometrial function: facts, urban legends, and an eye to the future Fertility and Sterility. 108(1):4-8
2017Implantation failure of endometrial origin: it is not pathology, but our failure to synchronize the developing embryo
with a receptive endometriumFertility and Sterility. 108(1):15-18
2017 Meta-signature of human endometrial receptivity: a meta-analysis and validation study of transcriptomic biomarkers Scientific Reports. 7(1):10077
2017Window of implantation transcriptomic stratification reveals different endometrial subsignatures associated with live
birth and biochemical pregnancyFertility and Sterility. 108(4):703-710.e3
2018 Implantation failure of endometrial origin: what is new?Current Opinion in Obstetrics and
Gynecology. PMID: 29889670
2018 Inter-cycle consistency versus test compliance in endometrial receptivity analysis testJournal of Assisted Reproduction and
Genetics. 2018 May 26. PMID: 29804174.
YEAR TITLE JOURNAL
Ruiz-Alonso, et al. Fertil Steril 2013
Ruiz-Alonso, et al. Fertil Steril 2013
Independent retrospective studies
2015Endometrial receptivity array: Clinical
application
J Hum Reprod Sci. 2015;
8(3):121-9.
2017
Efficacy of the endometrial receptivity
array for repeated implantation failure in
Japan: A retrospective, two-centers study.
Reprod Med Biol.
2018
The role of the endometrial receptivity
array (ERA) in patients who have failed
euploid embryo transfers
J Assist Reprod Genet
2018; 35(4): 683-92.
YEAR TITLE JOURNAL
ERA RCT – Study protocol overview
Population: IVF patients at their first appointment undergoing blastocyst transfer
Primary objectives Secondary objectives
LB and cumulative LB rates at 1-year follow-up
(pET versus FET and pET versus ET)
Implantation and pregnancy rates, biochemical and
clinical miscarriages, ectopic pregnancy, obstetrical,
neonatal outcomes and cost-effectiveness.
Day 5/6
pET FET ET
Transfer
Thawed embryos
Cryopreserved embryos
HRT
ERA
01954758
(1st Release: Sep 26th, 2013)
(Last update: Nov 4th, 2018)
First IRB/EC approval July 2, 2013
EC FWA# 00027749
Last IRB/EC approval April 28, 2016
FPFI October 2013
Last LB (LPLV) September 2018
Study length 5 years
Recruitment length 4 years
ERA RCT Study Sites
16 Active sites worldwide
Participant sites
Enrolled patients (n)
N EXPECTED 546
IRB/EC APPROVED SITES 16
N RECRUITED 569
(339)
(17)
(39)
(7)
(116)
(14)
(20)
(11)(6)
Inclusion Criteria
1. Patients undergoing IVF at the first appointment
2. Age ≤ 37 years
3. BMI: 18.5 to 30
4. Normal ovarian reserve (AFC > 8; FSH < 8)
5. The stimulation protocol was decided by the doctor
6. Blastocyst transfer (day 5 or 6)
Exclusion Criteria
1. Recurrent miscarriage
2. Severe male factor (< 2 million/ml)
3. Implantation failure (>3 failed cycles)
4. Any pathology affecting the endometrial
cavity and hydrosalpinx must be previously
operated
Post-Randomization Exclusion Criteria
1. P4 level > 1,5 ng/ml at the day of hCG administration in all groups
2. Absence of blastocysts for embryo transfer
3. Risk of OHSS in the fresh ET group
Note. PGT-A was NOT an inclusion criteria NEITHER an exclusion criteria
ERA RCT Selection criteria
CONSORT Flow Diagram – ERA RCT
569 assessed for eligibility
458 randomized
Total 111 declined randomization51 did not meet selection criteria 43 declined to participate 8 double randomization by mistake6 site exclusion due to data inconsistency and submitted out of deadline 3 inclusion error
154 allocated to frozen ET
Enrollment
Allo
cati
on
Follo
w u
pA
nal
ysis
92 followed up after the first ET
148 ITT analysis92 per protocol analysis
137 proceeded with ET
6 Lost FU
92 proceeded with FET
45 no protocol compliance 3 embryo day 3 ET 1 embryo day 4 ET 22 had Fresh ET 5 had pET13 high P4 in COS1 ovum donation
148 allocated to personalized ET
80 followed up after the first ET
141 ITT analysis80 per protocol analysis
132 proceeded with ET
81 proceeded with PET
51 no protocol compliance 1 embryo day 3 ET 5 embryo day 4 ET 10 had Fresh ET 7 had Frozen ET 18 High P4 in COS7 no pET2 other treatment (INVO) 1 protocol deviation
1 voluntary termination of pregnancy
156 allocated to fresh ET
94 followed up after the first ET
145 ITT analysis94 per protocol analysis
138 proceeded with ET
95 proceeded with day ET
43 no protocol compliance2 embryo day 2 ET 8 embryo day 3 ET 1 embryo day 4 ET and high P4 in COS6 had Frozen ET13 had Frozen ET due to OHSS risk 1 had pET (n=1)12 high P4 in COS
1 voluntary termination of pregnancy
141 Followed up
7 Lost FU 11 Lost FU
145 Followed up 9 did not received ET
7 no blastocyst for ET2 spontaneous pregnancy
7 did not received ET 1 no ET data 3 no blastocyst for ET2 cancelled due to OHSS risk 1 spontaneous pregnancy
148 Followed up
11 did not received ET 2 no ET data6 no blastocyst for ET 3 spontaneous pregnancy
CONSORT Flow Diagram – ERA RCT
458 randomized
154 allocated to frozen ETAllo
cati
on
Follo
w
up
An
alys
is
6 Lost FU
148 allocated to personalized ET 156 allocated to fresh ET
7 Lost FU 11 Lost FU
141 ITT analysis 148 ITT analysis 145 ITT analysis
Follo
w u
pA
nal
ysis 92 PP analysis
137 proceeded with ET
92 proceeded with FET
45 no protocol compliance 3 embryo day 3 ET 1 embryo day 4 ET 22 had Fresh ET 5 had pET13 high P4 in COS1 ovum donation
80 PP analysis
132 proceeded with ET
81 proceeded with PET
51 no protocol compliance 1 embryo day 3 ET 5 embryo day 4 ET 10 had Fresh ET 7 had Frozen ET 18 High P4 in COS7 no pET2 other treatment (INVO) 1 protocol deviation
1 voluntary termination of pregnancy
94 PP analysis
138 proceeded with ET
95 proceeded with day ET
43 no protocol compliance2 embryo day 2 ET 8 embryo day 3 ET 1 embryo day 4 ET and high P4 in COS6 had Frozen ET13 had Frozen ET due to OHSS risk 1 had pET (n=1)12 high P4 in COS
1 voluntary termination of pregnancy
141 ITT analysis 145 ITT analysis9 did not received ET
7 no blastocyst for ET2 spontaneous pregnancy
7 did not received ET 1 no ET data 3 no blastocyst for ET2 cancelled due to OHSS risk 1 spontaneous pregnancy
148 ITT analysis11 did not received ET
2 no ET data6 no blastocyst for ET 3 spontaneous pregnancy
CONSORT Flow Diagram – ERA RCT
PersonalizedEmbryoTransfer. pET(n = 148) FrozenEmbryoTransfer. FET (n = 154) FreshEmbryoTransfer. ET (n = 156)
Age (y) 33 ± 3.1 32.8 ± 3.4 32.7 ± 3.3Body-mass index§ 22.8 ± 2.9 22.9 ± 2.9 22.6 ± 2.8Ethnicity (%)
Caucasian 122 (82.4) 127 (82.5) 129 (82.7)Asian 12 (8.1) 12 (7.8) 11 (7.1)Latin American 13 (8.8) 11 (7.1) 13 (8.3)African 0 (0.0) 4 (2.6) 1 (0.6)Other or unknow 1 (0.6) 0 (0.0) 2 (1.2)
Current smoker 15 (10.1) 12 (7.8) 15 (9.6)Fertility history
Duration of infertility (y) 3.1 ± 1.9 3.2 ± 2.1 2.9 ± 2.2No. of previous IVF failed
0 109 (73.6) 104 (67.5) 112 (71.8) 1 20 (13.5) 23 (14.9) 22 (14.1)2 10 (6.7) 10 (6.5) 12 (7.7)3 6 (4.0) 11 (7.1) 6 (3.8)
Previous Deliveries 1 11 (7.4) 16 (10.3) 17 (10.9)≥2 3 (2.0) 4 (2.6) 3 (1.9)
Spontaneous clinical miscarriages1 23 (15.5) 26 (16.9) 24 (15.4)≥2 6 (4.0) 3 (1.9) 0 (0.0)
Voluntary abortions 3 (2.0) 9 (5.8) 8 (5.1)
Previous curettages (1 or 2) 12 (8.1) 11 (7.1) 10 (6.4)
Ectopic pregnancies 8 (5.4) 3 (1.9) 4 (2.6)
IVF indication (%)
Male factor 65 (43.9) 78 (50.6) 50 (32.1)
Tubal factor 20 (13.5) 31 (20.1) 33 (21.1)
PCOS 27 (18.2) 20 (12.9) 14 (8.9)
Ovarian disorders 4 (2.7) 5 (3.2) 7 (4.5)
Endometriosis 21 (14.2) 9 (5.8) 13 (8.3)
Unexplained 33 (22.3) 33 (21.4) 47 (30.1)
Other or unknown‡ 2 (1.3) 4 (2.6) 10 (6.4)
Laboratory tests
FSH (mU/mL) 5.9 ± 1.9a 6.6 ± 2.1 6.9 ± 2.0b
AMH (ng/nL) 4.4 ± 3.6 3.7 ± 2.7 3.5 ± 2.9
Demographic and clinical characteristics of the patients at baseline
PersonalizedEmbryo Transfer. pET (n = 141) Frozen Embryo Transfer. FET (n = 148) FreshEmbryo Transfer. ET (n = 145)
AFC 14.8 ± 6.3 14.9 ± 6.6 13.1 ± 5.9Antagonist protocol 124 (87.9) 120 (81.1) 122 (84.1)Agonist protocol 10 (7.1) 13 (8.8) 12 (8.3)
Total dose of FSH administered (IU) 1696.9 ± 687.8 1540.2 ± 635.2 1666.1 ± 669.8Total dose of hMG administered (IU) 1167.03 ± 936 1202.3 ± 987 1165.1 ± 1042.5P level at the day of ovulation induction 1.02 ± 0.7 0.93 ± 0.6 0.92 ± 0.8Ovulation induction
hCG 62 (44.0)a 57 (38.5)a 110 (75.9)b
Agonist 62 (44.0)a 67 (45.3)a 15 (10.3)b
Double triggering 7 (5.0) 7 (4.7) 7 (4.8)Oocytes retrieved 12.4 ± 7.6 11.6 ± 6.0 10.5 ± 6.6Fertilization technique
ICSI 106 (75.2) 114 (77.0) 111 (76.6)IVF 5 (3.5) 6 (4.1) 9 (6.2)IVF/ICSI 21 (14.9) 13 (8.8) 21 (14.5)
Fertilization rate 1244/1633 (76.2) 1197/1531 (78.2) 1067/1379 (77.4)Embryo Stage
Cleavage stage 1/181 (0.6) 0 (0.0)a 7/211 (3.3)b
Morula 2/181 (1.1) 1/208 (0.5) 1/211 (0.5)Early Blastocyst 12/181 (6.6) 11/208 (5.3) 5/211 (2.4)Cavitated blastocyst 40/181 (22.1) 47/208 (22.6) 48/211 (22.7)Expanded Blastocyst 93/181 (51.4) 100/208 (48.1) 109/211 (51.7)Hatching Blastocyst 33/181 (18.2) 49/208 (23.6) 41/211 (19.4)
Blastocyst development rate 648/1248 (51.9) 636/1239 (51.3) 561/1093 (51.3)Day of embryo development at transfer
2 0 (0.0) 0 (0.0) 2 (1.4)3 10 (7.1) 4 (2.7) 10 (6.9)4 7 (5.0)a 4 (2.7) 0 (0.0)b
5 98 (69.5)a 112 (75.7) 119 (82.1)b
6 16 (11.3) 17 (11.5)a 6 (4.1)b
Embryo QualityICM"A" grade 48/149 (32.2) 70/183 (38.3) 56/183 (30.6)"B" grade 84/149 (56.4) 92/183 (50.3) 110/183 (60.1)"C" grade 17/149 (11.4) 21/183 (11.5) 17/183 (9.3)
TE"A" grade 36/149 (24.2) 56/183 (30.6) 46/183 (25.1)"B" grade 85/149 (57) 95/183 (51.9) 96/183 (52.5)"C" grade 28/149 (18.8) 32/183 (17.5) 40/183 (21.9)
PGT-A cases 6 (4.3) 4 (2.7) 3 (2.1)Number of transferred embryos 1.52 ± 0.5 1.61 ± 0.5 1.63 ± 0.5Thawed HRT embryo transfer data
No. of days of E2 15.5 ± 3.8a 16.6 ± 3.8b NAEndogenous P levels¶ 0.2 (0.03-1.4) 0.29 (0.05-11.03) NAHours exogeneous P admin. 120 ± 14.4 117.8 ± 9.7 NAHours exogeneous P admin. (range) 65.2-163.4 (98.2) 66.4-151.2 (84.8) NATime between COS and embryo transfer (months) 3.2 ± 2.4a 2.1 ± 1.4b NA
Cycle characteristics and embryological data. ITT analysis
pET (n = 141) FET (n = 148) ET (n = 145)pET vs FET pET vs ET
Relative risk (95% CI) P-value Relative risk (95% CI) P-value
No. of transfers 132 137 138
Pregnancy rate 83 (58.9) 73 (49.3) 84 (57.9) 1.22 (0.96-1.56) 0.12 1.02 (0.80-1.29) 0.9
Implantation rate 88/201 (43.8) 80/220 (36.4) 97/225 (43.1) 1.17 (0.96-1.43) 0.14 1.01 (0.83-1.24) 0.92
LB rate 57 (40.4) 51 (34.5) 64 (44.1) 1.14 (0.90-1.44) 0.33 0.92 ( 0.73-1.18) 0.55
Singleton 49/57 (86) 40/51 (78.4) 45/64 (70.3) 1.31 (0.75-2.29) 0.32 1.76 (0.95-3.25) 0.049
Multiple (all twins) 8/57 (14) 11/51 (21.6) 19/64 (29.7) 0.76 (0.44-1.34) 0.32 0.57 (0.31-1.05) 0.049
Clinical miscarriages 17/83 (20.5) 11/73 (15.1) 5/84 (5.9) 1.18 (0.84-1.66) 0.41 1.70 (1.27-2.27) 0.006
Biochemical pregnancies 7/83 (8.4) 9/73 (12.3) 11/84 (13.1) 0.81 (0.45-1.43) 0.44 0.76 (0.42-1.39) 0.46
Ectopic pregnancies 1/83 (1.2) 1/73 (1.4) 1/84 (1.2) 0.93 (0.24-3.79) 1 1 (0.25-4.06) 1
No. of patients with surplus embryo
transfers57 (40.4) 57(38.5) 42 (28.9) 1.04 (0.82-1.32) 0.81 1.28 (1.02-1.62) 0.047
Total No. of surplus cycles and transfers 150 130 110
Cumulative No. of transfers 282 267 248
No. of pregnancies from surplus embryo ET 49 45 33
Cumulative pregnancy rate 132/141 (93.6)a 118/148
(79.7)b
117/145
(80.7)b 2.29 (1.27-4.11) 0.0005 2.18 (1.22-3.89) 0.0013
Cumulative LB rate 88/141 (62.4) 82/148 (55.4) 85/145 (58.6) 1.16 (0.91-1.49) 0.23 1.08 (0.85-1.39) 0.55
Singleton 75/88 (85.2) 67/82 (81.7) 58/85 (68.2) 1.14 (0.74-1.74) 0.54 1.73 (1.08-2.78) 0.011
Multiple (all twins) 13/88 (14.8) 15/82 (18.3) 27/85 (31.8) 0.88 (0.57-1.35) 0.54 0.58 (0.36-0.92) 0.011
Cumulative clinical miscarriages 24/132 (18.2) 17/118 (14.4) 5/117 (4.3) 1.13 (0.85-1.51) 0.49 1.69 (1.36-2.09) 0.0006
Cumulative biochemical pregnancies 19/132 (14.4) 16/118 (13.6) 23/117 (19.7) 1.03 (0.74-1.44) 1 0.83 (0.58-1.18) 0.31
Cumulative ectopic pregnancies 1/132 (0.8) 1/118 (0.8) 1/117 (0.9) 0.95 (0.24-3.81) 1 0.94 (0.23-3.79) 1
Transfers per patient 2.63 ± 1.14 2.28 ± 0.70 2.62 ± 0.73 0.35 (-0.4-0.4) 0.1 0.01 (-0.43-0.45) 1
Reproductive outcomes at the first embryo transfer and cumulative during 1-year follow-up*.
ITT analysis
Cumulative Pregnancy Rate
pET (n = 141) FET (n = 148) ET (n = 145)
pET vs FET pET vs ET
Relative risk (95% CI) P-value Relative risk (95% CI) P-value
132/141 (93.6 %)a 118/148 (79.7%)b 117/145 (80.7%)b 2.29 (1.27-4.11) 0.0005 2.18 (1.22-3.89) 0.0013
pET (n = 80) FET (n = 92) ET (n = 94)pET vs FET pET vs ET
Relative risk (95% CI) P-value Relative risk (95% CI) P-value
Pregnancy rate 58 (72.5) 50 (54.3) 55 (58.5) 1.56 (1.07-2.29) 0.01 1.42 (0.98-2.08) 0.057
Implantation rate 63/110 (57.3) 60/139 (43.2) 58/150 (38.6) 1.37 (1.03-1.82) 0.03 1.54 (1.15-2.05) 0.004
LB rate 45 (56.2) 39 (42.4) 43 (45.7) 1.35 (0.97-1.86) 0.09 1.26 (0.91-1.74) 0.17
Singleton 40/45 (88.9) 30/39 (76.9) 33/43 (76.7) 1.60 (0.77-3.33) 0.16 1.64 (0.78-3.46) 0.16
Multiple (all twins) 5/45 (11.1) 9/39 (23.1) 10/43 (23.2) 0.62 (0.30-1.30) 0.16 0.60 (0.29-1.28) 0.16
Clinical miscarriages 9/58 (15.2) 7/50 (14) 3/55 (5.4) 1.06 (0.66-1.69) 1 1.55 (1.05-2.27) 0.13
Biochemical pregnancies 4/58 (6.9) 4/50 (8) 8/55 (14.5) 0.93 (0.45-1.89) 1 0.62 (0.27-1.42) 0.23
Ectopic pregnancies 0 (0.0) 0 (0.0) 1 (1.8)
No. of patients with surplus embryo
transfers19 (23.7) 16 (17.4) 4 (4.2)
Total No. of surplus cycles and transfers 39 18 10
Cumulative No. of transfers 119 110 104
No. of pregnancies from surplus embryo
transfers18 15 4
Cumulative pregnancy rate 76/80 (95) 65/92 (70.6) 59/94 (62.8) 4.18 (1.65-10.56) 0.0001 5.49 (2.14-14.06) 0.0001
Cumulative LB rate 57 (71.2) 51 (55.4) 46 (48.9) 1.47 (1.01-2.13) 0.04 1.71 (1.17-2.49) 0.003
Singleton 51/57 (89.5) 41/51 (80.4) 34/46 (73.9) 1.48 (0.76-2.86) 0.28 1.80 (0.92-3.54) 0.066
Multiple (all twins) 6/57 (10.5) 10/51 (19.6) 12/46 (26.1) 0.68 (0.35-1.31) 0.28 0.55 (0.28-1.09) 0.066
Cumulative clinical miscarriages 10/76 (13.2) 8/65 (12.3) 3/59 (5.1) 1.03 (0.66-1.61) 1 1.42 (1.01-1.99) 0.15
Cumulative biochemical pregnancies 9/76 (11.8) 6/65 (9.2) 9/59 (15.3) 1.13 (0.72-1.76) 0.78 0.87 (0.54-1.42) 0.62
Cumulative ectopic pregnancies 0 (0.0) 0 (0.0) 1/59 (1.7)
Transfers per patient 3.05 ± 1.61 2.13 ± 0.34 3.5 ± 1.29 0.92 (-0.11-1.97) 0.09 -0.45 (-2.13-1.24) 1
Reproductive outcomes at the first embryo transfer and cumulative during 1-year follow-
up*. Per protocol analysis
pET (n = 80) FET (n = 92) ET (n = 94)
pET vs FET pET vs ET
Relative risk
(95% CI) P-value
Relative risk
(95% CI) P-value
Pregnancy rate 58 (72.5%) 50 (54.3%) 55 (58.5%) 1.56 (1.07-2.29) 0.01 1.42 (0.98-2.08) 0.057
Implantation rate 63/110 (57.3%) 60/139 (43.2%) 58/150 (38.6%) 1.37 (1.03-1.82) 0.03 1.54 (1.15-2.05) 0.004
LB rate 45 (56.2%) 39 (42.4%) 43 (45.7%) 1.35 (0.97-1.86) 0.09 1.26 (0.91-1.74) 0.17
Cumulative
pregnancy rate76/80 (95%) 65/92 (70.6%) 59/94 (62.8%) 4.18 (1.65-10.56) 0.0001 5.49 (2.14-14.06) 0.0001
Cumulative LB
rate57 (71.2%) 51 (55.4%) 46 (48.9%) 1.47 (1.01-2.13) 0.04 1.71 (1.17-2.49) 0.003
Personalized-Embryo Transfer. pET (n = 80)
Frozen-Embryo Transfer. FET (n = 92) Fresh-Embryo Transfer. ET (n = 94)
No. of outcomes No. of outcomes No. of outcomes
Ovarian hyperstimulation 80 0 (0.0) 92 0 (0.0) 94 1 (1.1)Obstetrical outcomes 45 39 43
Gestational diabetes 2 (4.4) 1 (2.6) 1 (2.3)HBP 1 (2.2) 0 (0.0) 0 (0.0)Placenta previa 1 (2.2) 1 (2.6) 0 (0.0)Retrocorial hematoma 0 (0.0) 1 (2.6) 1 (2.3)Abruption 1 (2.2) 0 (0.0) 0 (0.0)Vasa previa 1 (2.2) 0 (0.0) 0 (0.0)Still birth 1 (2.2) 1 (2.6) 0 (0.0)
Type of delivery 40 35 43C-Section 10 (25.0) 14 (40.0) 15 (34.9)Vaginal 30 (75.0) 21 (60.0) 28 (65.1)
Neonatal outcomes‡ 40 35 43Neonatal mortality 0 (0.0) 1 (2.9) 0 (0.0)Gestational age
(weeks)38 38.03 ± 3.1 34 38.03 ± 2.9 42 38.33 ± 1.6
Preterm birth <37 weeks
38 5 (13.2) 34 6 (17.6) 42 4 (9.5)
Birth weight (g) 23 3170.6 ± 646.9 302868.5 ±
629.134 2912.6 ± 573.6
Birth weight in singletons
17 3484.4 ± 321.6 14 3362.5 ± 402 223210.68 ±
375.6
Birth weight in twins 6 2281.7 ± 476.7 162436.2 ±
444.912 2366.2 ± 463.2
Birth weight <2500 g 23 4 (17.4) 30 10 (33.3) 34 6 (17.6)
Obstetrical, delivery and neonatal outcomes. Per protocol analysis
Personalized-Embryo Transfer pET (n = 80)
Frozen-EmbryoTransfer FET (n = 92)
Fresh-EmbryoTransfer ET (n = 94)
No. of deliveries with at least 1 LB at the first attempt
45 39 43
EU USA EU USA EU USA
IVF lab cost € 5.190 $ 11.825 € 5.190 $ 11.825 € 5.590 $ 12.325
Drug cost € 1.700 $ 5.500 € 1.600 $ 4.700 € 1.580 $ 4.500
Vitrification cost € 1.100 $ 1.375 € 1.100 $ 1.375 - -
Additional cost in pET and FET € 2.050 $ 3.500 € 2.050 $ 3.500 - -
Cost of ERA € 710 $ 795 - - - -
Mock cycle € 250 $ 1.000 - - - -
Total cost per embryo transfer
€ 11.000 $ 23.995 € 9.940 $ 21.400 € 7.170 $ 16.825
Estimated cost of a delivery with at least 1 LB at the first attempt
€ 19.555 $ 42.658 € 23.448 $ 50.482 € 15.674 $ 36.780
Cost-effectiveness estimation per baby at home at the first attempt
Personalized-Embryo Transfer pET (n = 80)
Frozen-EmbryoTransfer pET (n = 92)
Fresh-EmbryoTransfer pET (n = 80)
EU USA EU USA EU USA
Estimated cost of a delivery with at least 1 LB at the first attempt
€ 19.555 $ 42.658 € 23.448 $ 50.482 € 15.674 $ 36.780
ERA RCT Take-home messages
✓ By ITT analysis,
Cumulative PR was significantly in the pET group (93.6%) vs FET (79.7%) and ET (80.7%).
✓ By PP analysis,
LB 14 pp and 11 pp versus FET and ET that was non statistically significant.
Statistically significant improvement in:
Cumulative LBR 16 pp and 22.1 pp versus FET and ET.
PR 18.2 pp and 14 pp versus FET and ET.
IR 14 pp and 18.4 pp versus FET and ET.
Cumulative PR 24.4 pp and 32.1 pp versus FET and ET.
✓ Similar clinical outcome between FET and ET.
✓ Obstetrical, delivery and neonatal outcomes were not different.
Simon C et al., Human Reprod submitted
Limitations, reasons for caution
✓ The main limitation of our study is the unexpected added 20% patient drop-
out rate versus 30% initially planned (16 study sites in 3 different continents).
✓ The study was powered to detect statistical differences for a 15-
percentage points increase in the primary outcomes in the pET group
versus FET or ET.
✓ This is the first RCT to provide proof-of-principle evidence for the potential of
using a personalized diagnosis of the endometrial factor in the work-up of
the infertile couple at the first appointment
Future Directions
1978 2010
IVF 1.0
ChromosomalEmbryo Factor1
5%
IVF 2.0
LIV
E B
IRTH
RA
TES %
5
15
25
35
45
55
65
10
20
30
40
50
60
Endometrial Factor1
5%
NCT03530254 (May 21, 2018)NCT3558399 (June 15, 2018)
Conclusions
✓ Precision medicine supported by contrasted basic researchtogether with clinical translation in an evidence-based medicineapproach should guide the improvement of our field
✓ Black box can be unravelled: Endometrial receptivity andmicrobiome are now actionable functions that can improve ourclinical practice
✓Clinical outcome of the personalized endometrial factor approachincreses cumulative PR per ITT and cumulative LBR and PR and PRand IR per protocol analysis
Research DirectorFelipe Vilella, PhD
Research ManagerInmaculada Moreno, PhD
ResearchersTamara Garrido, PhD
Aymara Mas, PhD
Medical ManagerDiana Valbuena, MD, PhD
Ruth Lathi, Stanford University
ERA Team
FINANCIAL SUPPORT
COLLABORATORS
David Blesa
Carlos Gómez
Diana Valbuena
Steve Quake LABSteve Quake
Wanxin Wang
Wenying Pan