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Immune checkpoints Tim-3/Gal-9 and PD-1/PL-1 are involved in the maintenance of maternal-fetal immune tolerance systematically and locally. This study aimed to compare the serial changes of Tim-3/Gal-9, and PD-1/PL-1 in peripheral blood over a 4-week period after blastocyst transfer, between women who had a live birth and those who miscarried.Serial blood samples were obtained on the day of ET, and 9, 16, 23, and 30 days after ET for the measurement of Tim-3 and PD-1 expressions on various lymphocytes by flow cytometry. Concentrations of serum Gal-9 and PD-L1 were measured by ELISA.In pregnancies that resulted in a live birth, a significant and sustained increase in the proportion of Tim-3A significant and sustained increase in the proportion of Tim-3

In women with a history of recurrent miscarriage, the uterine CD56+ cell density in subjects with subsequent euploid miscarriage was significantly higher than those with subsequent aneuploid miscarriage. Both endometrial and embryonic factors should be investigated when interpreting uterine CD56+ cell density results relating to recurrent miscarriage.

In women with a history of recurrent miscarriage, the uterine CD56+ cell density in subjects with subsequent euploid miscarriage was significantly higher than those with subsequent aneuploid miscarriage. Both endometrial and embryonic factors should be investigated when interpreting uterine CD56+ cell density results relating to recurrent miscarriage.

Objective To compare the changing peripheral levels of immune checkpoint proteins T-cell immunoglobulin mucin-3 (Tim-3)/galectin-9 (Gal-9), and programmed cell death-1 (PD-1)/programmed death-ligand 1 (PD-L1) over a 9-day period after blastocyst transfer between women who did and did not conceive. Design Prospective observational study. Setting University teaching hospital. Patients(s) Fifty-one infertile women undergoing day-5 blastocyst transfer. Intervention(s) Serial blood samples obtained on the day of embryo transfer (ET), and 3, 6, and 9 days afterward for measurement of membranous Tim-3 and PD-1 expression on various peripheral lymphocytes by flow cytometry, and serum concentrations of ligands Gal-9 and PD-L1 by ELISA. Main Outcome Measure(s) Membranous Tim-3 and PD-1 expression on lymphocytes and serum Gal-9 and PD-L1 concentrations and comparison of results between pregnant and nonpregnant women. Result(s) In women who conceived, the measurements exhibited three different types of response: [1] a transient and statistically significant reduction of Tim-3+NK-like T cells, Tim-3+/PD-1+CD8+ T cells, and Tim-3+/PD-1+CD4+ T cells that returned back to baseline level 9 days after ET; [2] a reduction followed by steady increase to above baseline level on day 9 (Tim-3+CD56dimNK cells); [3] a steady increase in expression after ET to reach a level statistically significantly higher than that of the baseline by day 9 (Tim-3+CD56brightNK cells). Women who did not conceive showed no statistically significant fluctuation in any of the parameters measured across the four time pointswith exception of increased Tim-3 expression on NK cells on day 9. Conclusion(s) Successful blastocyst implantation is associated with a reduction of Tim-3 and PD-1 expression in peripheral lymphocytes on days 3 and 6 that is no longer apparent on day 9.

Objective To compare the expression pattern of angiogenic cytokines in CD56+ uNK cells from peri-implantation endometrium in women with a history of recurrent miscarriage and fertile controls. Methods 28 women were recruited, from which 18 women were diagnosed as recurrent miscarriage and 10 women were of proven fertility. Endometrial biopsy samples were obtained precisely 7 days after luteinization hormone surge in a natural cycle. The angiogenic profile of isolated CD56+ uNK cells was determined by RayBio human angiogenesis antibody array G Series 1000. Differentially expressed angiogenic cytokines between groups were validated by ELISA kits. Results CD56+ uNK cells freshly isolated from peri-implantation endometrium were determined to be >90% pure. Angiogenic cytokine array demonstrated that CD56+ uNK cells are one of the angiogenic factors producers in endometrium around the time of embryo implantation. A differential angiogenic cytokine expression profile was found between two groups, with significantly higher expressions of angiogenin, VEGF-A and bFGF in CD56+ uNK cells from women with recurrent miscarriage, compared with fertile controls. Conclusions Differential angiogenic cytokine profile of isolated CD56+ uNK cells suggested the role of uNK cells in the altered endometrial vascularity at the time of implantation, which may account for the endometrial contribution to recurrent miscarriage.

Research Question Does music therapy help in reducing pain and anxiety in women undergoing transvaginal ultrasound-guided oocyte retrieval (TUGOR)? Design In this randomized controlled open label study, 209 participants were recruited and randomized into three groups (music group, n = 70; headphone group, n = 70; control group, n = 69). Patients' psychological status was assessed using the visual analogue scale of pain (VAS-P), satisfaction of pain control, state-trait anxiety inventory (STAI), Beck depression inventory (BDI), and general health questionnaire (GHQ). Stress biomarkers, including salivary alpha amylase (sAA) and salivary cortisol (sCort), were measured before and after TUGOR. Results No significant differences were found in psychological scoring of STAI, BDI, GHQ and the stress biomarkers. Although neither the anxiety scores nor the analgesic requirements differed among the three groups, the visual measure of vaginal pain (median, range) showed music group (20,0–70) was significantly ( P = 0.005) lower than headphone group (30,0–90) and control group (30,0–100). The degree of satisfaction with pain control (median, range) in the music group (80,30–100), was significantly ( P = 0.001) higher than the headphone group (80,10–100) and control group (70,0–100). Conclusion Music is a simple, inexpensive and effective way to reduce pain score and increase satisfaction with pain control during TUGOR procedure, which may justify its routine use.

AIM This aim of this study was to determine the association between uterine natural killer (uNK) cell density and chronic endometritis (CE). METHODS Endometrial biopsies from 135 women with recurrent miscarriage were obtained precisely 7 days after luteinizing hormone surge in natural cycles. Endometrial sections were immunostained for CD56 for uNK cells and CD138 for plasma cells, respectively. Uterine NK cell counting was performed according to a standardized protocol and results were expressed as percentage of CD56+ cells/ total stromal cells. High uNK cell density was defined as >4.5% and CE was diagnosed when the plasma cell density > 5.15 cells/ 10 mm2 . RESULTS The uNK cells density in women with CE (median, 5.1%; range, 3.4-8.8%) was significantly (P

Background In Hong Kong, one of six couples is affected by subfertility problems. Male infertility contributes to half of the infertility cases. In male infertility, there is no effective treatment for patients with idiopathic infertility/poor semen parameters. Recent meta-analysis results suggest that a traditional Chinese medicine (TCM) formula — Wuzi Yanzong pill — showed a curative effect on male fertility. However, the heterogeneity of the studies could not draw a definitive conclusion on the therapeutic effect of this formula. The aim of this study is to conduct a well-designed randomized controlled trial to investigate the effect of TCM formula Wuzi Yanzong pill on improving semen qualities in men with suboptimal parameters. Methods This study is a double-blinded, randomized placebo-controlled trial conducted in a public hospital in Hong Kong. Participants will be randomized, using computer-generated random numbers, with a 1:1 ratio to either the Wuzi Yanzong pill formula group or the placebo group. Both groups will be administered the drugs for 12 weeks. Participants will have a total of four visits for their semen and blood assessments for a 6-month period, and we will follow up for another 6 months to record their conception outcome. The primary outcome is to compare the total motile sperm count, natural conception rate, and pregnancy outcome to those under placebo treatment. Secondary objectives are sperm functions and assisted reproductive technology outcome. Discussion To date, there are no studies using the disclosed Wuzi Yanzong formula or double-blinded, randomized trials. The Wuzi Yanzong TCM formula may provide a good clinical solution for subfertile males for which contemporary western medicine has no cure. Therefore, a well-designed randomized trial for evaluating the effect of Wuzi Yanzong TCM formula is urgently needed. Trial registration Chinese Clinical Trial Registry (ChiCTR), ChiCTR-INR-17010790. Registered on 27 February 2017. Centre for Clinical Research and Biostatistics - Clinical Trials Registry, CUHK_CCRB00548. Registered on 27 February 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3647-2) contains supplementary material, which is available to authorized users.

PROBLEM A reference range for uterine natural killer (uNK) cell density in the peri-implantation period has recently been established in natural cycles. However, it is uncertain whether the results can be applied to hormonal replacement therapy (HRT) cycles, used increasingly in frozen-thaw embryo replacement cycles and which is known to be capable of supporting implantation. METHOD OF STUDY A total of 183 women from two IVF centers participated in this study, including 75 women in natural cycles and 108 women in HRT cycles. All endometrial biopsies were collected precisely on the putative day of embryo implantation, namely 7 days after LH surge (LH+7) of the natural cycles or 5 days after initiation of progesterone (P+5) of the HRT cycles. Endometrial sections were immunostained for CD56 for uNK cells. Cell counting was performed by a standardized protocol, and results were expressed as percentage of positive uNK cells/total stromal cells. RESULTS There was no significant difference (P > 0.05) in uNK cell density between natural cycles (median 2.28%, range 0.99%-4.78%) and HRT cycles (median 2.55%, range 0.69%-5.02%) in women undergoing IVF-ET treatment on the putative day of blastocyst transfer. Using reference range from 1.2% to 4.5% for uNK cell density, there was no significant difference (P > 0.05) in high uNK cell density proportion between natural cycles (8%, 6/75) and HRT cycles (10.2%, 11/108). CONCLUSION The results indicated that the reference range for uNK cell density derived from natural cycles may apply to HRT cycles.

Background and objective: Endometrial angiogenesis is a prerequisite for successful pregnancy. Optical coherence tomography (OCT) is a non-invasive physically optical imaging technique widely used in ophthalmology and cardiology. However, there is no study using OCT to evaluate endometrium. The aim of this study was to use OCT and traditionally histological methods to investigate endometrial vascularization in women undergoing in vitro fertilization-embryo transfer (IVF-ET) treatment and to determine the association with the pregnancy outcome. Methods: A total of 47 women were included in this study. OCT was used to assess endometrial vascularization by determining the high signal areas precisely on the seventh day after luteinizing hormone surge in non-conception natural cycles. Endometrial biopsies were obtained following OCT and immunohistochemistry was used to determine micro vessel and expression of vascular endothelial growth factor-A (VEGF-A) in the luminal epithelium, glandular epithelium and stroma, separately. Micro vessel counting was performed and the result was expressed as micro vessel density (MVD). A semi-quantitative H-score was used to determine the staining intensity of VEGF-A. Results: In women who successfully conceived after embryo transfer, the proportion of extensive high signal area in the uterine body detected by OCT (80%, 8/10), MVD (median number of micro vessels/mm2 of 10, range 4&ndash, 17) and stromal expression of VEGF-A (median H-score of 189, range 72&ndash, 395) were found to be significantly higher than those of women who did not conceive after embryo transfer in the subsequent IVF-ET treatment (OCT: 30%, 3/10, MVD: median number of micro vessels/mm2 of 7, range 4&ndash, 10, VEGF-A: median H-score of 125, range 86&ndash, 299, respectively). In addition, a significantly higher stromal expression of VEGF-A (median H-score of 196, range 84&ndash, 395) and MVD (median number of micro vessels/mm2 of 9, range 5&ndash, 16) was found in women with extensive high signal area in uterine body, compared to those with focal or no high signal area (stromal VEGF-A: median H-score of 135, range 92&ndash, 302, MVD: number of micro vessels/mm2 of 6, range 4-11). Conclusions: Both immunohistochemistry and OCT demonstrated significant difference in vascularization of the peri-implantation endometrium between subjects who did and did not conceive after IVF-ET treatment. Our findings also suggest OCT appears to be a promising non-invasive or minimally invasive alternative to study endometrial vascularity in women with reproductive failure.

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Aim To study the transcriptome profiles in the blood of recurrent implantation failure (RIF), recurrent miscarriage (RM) and fertile women during the window of implantation, and further analysis the correlation of transcriptome profiles between blood and endometrium. Methods This is an observational prospective study. In total 9 subjects were recruited, 3 RIF, 3 RM, and 3 controls. Paired samples (endometrium and peripheral blood) from the same subjects were precisely timed on the 7th days after luteal hormone surge (LH+7). RNA sequencing was applied to investigate the transcriptome profiles. Results The results of transcriptome in peripheral blood cannot be used to characterize women with RIF and unexplained RM. There was a medium level correlation between transcriptome in peripheral blood and endometrium during the window of implantation. Conclusion The differential transcriptome patterns in blood are not representative of those in endometrium, and the blood transcriptome cannot differentiate among the women with RIF, RM or fertile.

Objective To systematically compare the endometrial microbiota in infertile women with and without chronic endometritis (CE), as diagnosed by a quantitative and reference range-based method. Design Case-control observational study. Setting University-affiliated hospital. Patient(s) One hundred and thirty infertile women. Intervention(s) Endometrial biopsy and fluid (uterine lavage, UL) collected precisely 7 days after LH surge, with plasma cell density (PCD) determined based on Syndecan-1 (CD138)-positive cells in the entire biopsy section and culture-independent massively parallel sequencing of the 16S ribosomal RNA gene performed on both the CE and non-CE endometrial fluid samples. Main Outcome Measure(s) Relative abundance of bacterial taxa. Result(s) Chronic endometritis was diagnosed if the PCD was above the 95th percentile (>5.15 cells per 10 mm2) of the reference range in fertile control subjects. With this stringent diagnostic criterion, 12 women (9%) were diagnosed with CE. Sequencing was successfully performed on all endometrial samples obtained by UL) (CE, n = 12; non-CE, n = 118). The median relative abundance of Lactobacillus was 1.89% and 80.7% in the CE and non-CE microbiotas, respectively. Lactobacillus crispatus was less abundant in the CE microbiota (fold-change, range: 2.10–2.30). Eighteen non-Lactobacillus taxa including Dialister, Bifidobacterium, Prevotella, Gardnerella, and Anaerococcus were more abundant in the CE microbiota (fold-change, 2.10–18.9). Of these, Anaerococcus and Gardnerella were negatively correlated in relative abundance with Lactobacillus (SparCC correlation magnitude, range: 0.142–0.177). Conclusion(s) Chronic endometritis was associated with a statistically significantly higher abundance of 18 bacterial taxa in the endometrial cavity. Clinical Trials Registry Number ChiCTR-IOC-16007882.

Background Women with a history of recurrent miscarriage are accorded dedicated medical care during a subsequent pregnancy (or subsequent pregnancies). Previous studies of subsequent pregnancy and perinatal outcome in women with a history of recurrent miscarriage give conflicting results, with some reporting an increase in adverse obstetric and perinatal outcomes, and others reporting no difference. There is a lack of systematic review based on a large-scale population. Methods We carried out a systematic review and meta-analysis to incorporate direct and indirect data from relevant studies. We searched PubMed, Scopus, Embase, Web of Science, and Ovid, up to Dec 31, 2017. Studies that were included were full text reports of pregnancy outcomes in women with a history of recurrent miscarriage. We used the random-effect model or the fixed-effect model to estimate the incidence of different obstetric and perinatal outcomes. We also carried out subgroup analysis to determine the effect of the sex of the fetus on the incidence of different obstetric and perinatal outcomes. Findings Among 1842 full articles retrieved, 7 articles with a total of 224 879 participants, including 10 174 women with a history of recurrent miscarriage and 21 4705 control subjects, were included in this systematic review and meta-analysis. Recurrent miscarriage was associated with a significantly increased incidence of antepartum haemorrhage (odds ratio [OR] 2·38, 95% CI 1·98–5·27), gestational diabetes (1·23, 1·02–1·47), preterm delivery (1·73, 1·28–2·07), small for gestational age (1·52, 1·19–1·98), and perinatal death (2·30, 1·62–4·97). There was no significant difference in the incidence of gestational hypertension, or in Apgar scores at 1 and 5 minutes after birth. There was also no significant difference in risk between male fetus and female fetus. Interpretation Women with a history of recurrent miscarriage have an increased risk of several obstetric and perinatal complications, and therefore may require more dedicated medical care in their subsequent pregnancies. Funding This work was supported by the Health and Medical Research Fund in Hong Kong (number 04152786) and the Hong Kong Obstetrical and Gynaecological Trust Fund in 2017.