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Does Flushing the Uterine Cavity With Follicular Fluid After Ovum Pick-up Improve Implantation Rates in ICSI Cycles?

Primary Purpose

Intra-cytoplasmic Sperm Injection Outcome

Status
Completed
Phase
Phase 1
Locations
Egypt
Study Type
Interventional
Intervention
Follicular fluid
Sponsored by
Nawara Mohamed Hashish
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Intra-cytoplasmic Sperm Injection Outcome focused on measuring Follicular Fluid, uterine cavity, Implantation rates, ICSI

Eligibility Criteria

20 Years - 38 Years (Adult)FemaleDoes not accept healthy volunteers

Inclusion Criteria:

  1. Maternal age ranges from 20-38 years.
  2. Basal FSH < 10 mIU/ml.
  3. BMI < 35 kg/m2.
  4. Estradiol level > 1000 at the day of HCG administration.
  5. Estradiol level < 4000 at the day of HCG administration.

Exclusion Criteria:

  1. Presence of Endometriosis.
  2. Presence of Hydrosalpinx.
  3. Presence of vaginal infection.
  4. Presence of galactorrhea.
  5. Presence of hormonal disorders.
  6. Severe male factor infertility:

    Sperm Count < one million. Marked malformation

  7. history of recurrent abortion.

Sites / Locations

  • Kasr El-Aini hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

No Intervention

Arm Label

follicular fluid group

control group

Arm Description

Follicular fluid group is the group in which flushing of the uterine cavity with follicular fluid after ovum pick-up is done.

Control group is the group in which flushing of the uterine cavity with follicular fluid after ovum pick-up is not done.

Outcomes

Primary Outcome Measures

pregnancy rate
The main outcome is the pregnancy rate in ICSI cycles after flushing the uterine cavity with follicular fluid after ovum pick-up in the study group and comparing it with the control group.

Secondary Outcome Measures

Implantation rate
The secondary outcome is the implantation rate in ICSI cycles after flushing the uterine cavity with follicular fluid after ovum pick-up in the study group and comparing it with the control group.

Full Information

First Posted
March 20, 2012
Last Updated
October 6, 2012
Sponsor
Nawara Mohamed Hashish
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1. Study Identification

Unique Protocol Identification Number
NCT01563822
Brief Title
Does Flushing the Uterine Cavity With Follicular Fluid After Ovum Pick-up Improve Implantation Rates in ICSI Cycles?
Official Title
Phase I Study of the Effect of Flushing the Uterine Cavity With Follicular Fluid After Ovum Pick-up on Implantation Rates in ICSI Cycles
Study Type
Interventional

2. Study Status

Record Verification Date
October 2012
Overall Recruitment Status
Completed
Study Start Date
December 2011 (undefined)
Primary Completion Date
June 2012 (Actual)
Study Completion Date
June 2012 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor-Investigator
Name of the Sponsor
Nawara Mohamed Hashish

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief 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.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Intra-cytoplasmic Sperm Injection Outcome
Keywords
Follicular Fluid, uterine cavity, Implantation rates, ICSI

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 1
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
100 (Actual)

8. Arms, Groups, and Interventions

Arm Title
follicular fluid group
Arm Type
Experimental
Arm Description
Follicular fluid group is the group in which flushing of the uterine cavity with follicular fluid after ovum pick-up is done.
Arm Title
control group
Arm Type
No Intervention
Arm Description
Control group is the group in which flushing of the uterine cavity with follicular fluid after ovum pick-up is not done.
Intervention Type
Biological
Intervention Name(s)
Follicular fluid
Intervention Description
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
Primary Outcome Measure Information:
Title
pregnancy rate
Description
The main outcome is the pregnancy rate in ICSI cycles after flushing the uterine cavity with follicular fluid after ovum pick-up in the study group and comparing it with the control group.
Time Frame
17 days
Secondary Outcome Measure Information:
Title
Implantation rate
Description
The secondary outcome is the implantation rate in ICSI cycles after flushing the uterine cavity with follicular fluid after ovum pick-up in the study group and comparing it with the control group.
Time Frame
17 days

10. Eligibility

Sex
Female
Minimum Age & Unit of Time
20 Years
Maximum Age & Unit of Time
38 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Maternal age ranges from 20-38 years. Basal FSH < 10 mIU/ml. BMI < 35 kg/m2. Estradiol level > 1000 at the day of HCG administration. Estradiol level < 4000 at the day of HCG administration. Exclusion Criteria: Presence of Endometriosis. Presence of Hydrosalpinx. Presence of vaginal infection. Presence of galactorrhea. Presence of hormonal disorders. Severe male factor infertility: Sperm Count < one million. Marked malformation history of recurrent abortion.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Nawara Mohamed Hashish, MD
Organizational Affiliation
Department of Obstetrics and Gynecology,Cairo University
Official's Role
Principal Investigator
Facility Information:
Facility Name
Kasr El-Aini hospital
City
Cairo
Country
Egypt

12. IPD Sharing Statement

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Does Flushing the Uterine Cavity With Follicular Fluid After Ovum Pick-up Improve Implantation Rates in ICSI Cycles?

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