Immunomodulation for unexplained recurrent implantation failure: where are we now?

In brief: Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies. Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of >= 3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.

Automated summary

Immune dysfunction can cause recurrent implantation failure. This article evaluates the immune responses during implantation and the effectiveness of immunomodulatory therapies. Recurrent implantation failure (RIF) is defined as the failure to achieve pregnancy after transferring at least 3 good-quality embryos, and its cause is unexplained in 50% of cases. Currently, there are no effective treatments for unexplained RIF. Modulating the maternal immune response during implantation is a recent strategy to improve conception rates in RIF patients, but there are no confirmed diagnostic tests for immune-mediated RIF.