*5.2.2. Results of the therapeutic invasion in the hemostatic and fibrinolytic systems administered for the increase in the number of successful IVF outcomes*

Correction of the hemostatic system at the excessive thrombin generation initially arranged the administration of heparin prophylaxis by means of subcutaneous introduction of nadroparin calcium (Sanofi-Aventis): 0.3 ml twice a day for 12-14 days. Decision to begin the therapy was based on marking a suprathreshold increase in the major indications of thrombin generation - ETP (over 1900 nM/min) and/or Peack thrombin concentration (over 360 nM/l) at the 2nd observation point.

92 Enhancing Success of Assisted Reproduction

The level of D-dimers, a known marker for fibrin generation and fibrinolysis, showed less distinctive differences in subgroups 1.1 and 1.2, even though it was slightly decreased, according to the mean data, in case of IVF failures (Table 2). Mean values of this indication in virtually healthy women of fertile age registered in our Center were equal to 205.3 ng/ml, with М ± 2SD 148.5 - 262.1 ng/ml. Respectively, registered results of the D-dimer level at the 2nd observation point were within the allowed value limits or slightly exceeded them.

It was more difficult to define the threshold values that reflect the decrease in the activity of fibrinolytic responses and allow specialists to select patients in need of hypofibrinolysis correction. Recent important publications devoted to this field demonstrate that hypofibrinolysis may be typical of some women who participate in the IVF procedure, but this pathology is original and not triggered in the course of controlled hormonal stimulation as a part of the IVF program (Martinez-Zamora et al., 2011; Westerlund et al. 2012). We received similar data proving that the suppression of fibrinolytic responses was actually typical of a number of women before the beginning of the IVF cycle. Suppression was steady throughout the cycle. Dynamics analysis of the changes in t-PA and PAI-1 activities, their EAAF index, and clot lysis time revealed more dramatic shifts at IVF failures, though the difference between the mean values of the parameters under study turned out to be invalid (P<0.05) (Table 2). Nevertheless, we have recorded two facts. First, mean values of the EAAF index defined in the group of 10 virtually healthy female volunteers (20-23 years) were equal (М±SD) to 11.0±3.3%. Second, in case of IVF failures we registered decreased EAAF indexes (less than 11%) in 93.5% (43 out of 46) of women in the 1st (observational) group before the start of the IVF program (1st observational point) as compared to 4,1% (2

out of 49) of women after successful impregnation (P<0.000001) (Table 3).

correlation between t-PA and PAI-1 activities, with the value of less than 11%.

*5.2.2. Results of the therapeutic invasion in the hemostatic and fibrinolytic systems* 

Correction of the hemostatic system at the excessive thrombin generation initially arranged the administration of heparin prophylaxis by means of subcutaneous introduction of

*administered for the increase in the number of successful IVF outcomes* 

114 women in subgroup 1.2), i.e. in 12.1 times (P<0,000001).

We used the values of the applied CLT assay to be the method of general fibrinolysis monitoring and refused to consider it as a potential criterion for the selection of women in need of therapeutic invasion in relation to its laboratory standardization. Thus, to select females to undergo IPC procedure we chose EAAF index calculation rate, which records the

Back to the data presented above and obtained during the study of the hemostasis and fibrinolysis systems in the patients of the 1st or observational group (n=163), one can see significant correlation between the detected pathologies and certain IVF outcomes (Table 3). Adverse shifts in these systems had records in 114 out of 163 women (70%) in the 1st group. In general, the IVF cycle efficacy at this stage of the study was equal to 34.4%, however, certain hemostatic and fibrinolytic pathologies facilitated the decrease in the number of successful impregnations from 95.9% (47 out of 49 women in subgroup 1.1) to 7.9% (9 out of


**Table 3.** IVF results in women of the 1st (observational) group depending on the presence or absence of hemostatic and fibrinolytic pathologies

Impact on the vessel wall to increase fibrinolytic activity was made by means of IPC. In the publication byKakkos et al. (2005) a comparative description of the two widely used compression machines - SCD Express™ Compression System (Tyco Healthcare Group LP, Mansfield, MA, USA) was introduced with a rapid inflation device that delivers uniform compression and VenaFlow® (Aircast Inc, Summit, NJ, USA). However neither of them is normally equipped with proper braces to provide mechanical invasion for arm vessels. Still, we found it important to compress this vessel area to exclude even the hypothetic possibilty


The Means of Progress in Improving the Results of *in vitro* Fertilization Based on the Identification and Correction of the Pathology of Hemostasis 95

of the pulmonary artery thromboembolia (e.g. in the presence of clinically non-evident iliofemoral thrombosis) and due to the obtained data on the increased content of t-Pa in endotelial vessels of the upper extremities (Pandolfi et al., 1968). That is why we chose pneumatic massaging device PM-01 (Russia) to apply a 7-chamber compression brace in the

chambers from 30 to 150 mm. Hg. Art., 45 cycles of compression wave with memory for 30 minutes to maintain the pressure in the cuff chambers from 5 to 90., the pressure of compressed air supplied to the compression performed in a course of 8 sessions (twice a week) with 30-minute cuff device to the left or right hand. The starting point of this therapy was to reduce EAAF index below 11% measured in a number of patients just prior to IVF

Studies have found that the total number of favorable outcomes of IVF in the 2nd (controlled) group was 41.5%, an increase of only 7.1%, compared with those in group 1

However, please note that 40 patients (subgroup 2.2.4) failed our proposed therapy, although prescribed by the above criteria. If to sum up the outcome of IVF in all samples in the study of women who had indications for treatment but did not receive it for a number of reasons (sub 1.2 and 2.2.4; 154 cases) we indicate positive results in 9.1%, whereas in the treated patients (subgroup 2.2.1, 2.2.2 and 2.2.3, 98 cases) - in 42.9%, or 4.71 times more

Effect of treatment produced on the dynamics of hemostasis and fibrinolysis during IVF is shown in Table 5. You can see the previous trends in Table 2, but the women in group 2, compared to the 1 st group demonstrated lower intensity of thrombin generation and

D-dimer levels in blood plasma has indicated growing trend - the concentration of this indicator has been consistently higher regardless of the period of the survey in patients with unsuccessful IVF outcome (Tables 2 and 5). However, the value of D-dimer levels was within the range of normal variation or slightly exceeded them, hardly matching the

In this regard, we have not put the emphasis on the results of this test upon the following

Other risk factors of unsuccessful IVF which did not depend on the characteristics of hemostatic and fibrinolytic had its effect on IVF success (see Section 2, Table 13, 14), as well as the fact of receiving or not receiving therapeutic intervention aimed at reducing the thrombogenic potential and increasing fibrinolytic activity of blood. Calculations and observations in tables 7-12 demonstrate a better pattern in this regard. In particular, it appeared that an approved prescription of low-molecular heparin at high thrombin generation at the 2nd stage of the study contributed to the increase in the incidence of pregnancy in 6.4 times (P<0,0001), isolated IPC course application -in 3.0 times (P<0,007), and the combination

of IPC course with heparin prophylaxis - in 6.5-times (P<0,0001) (Table 7).

improvement of fibrinolysis regardless of the outcome of IVF.

identified changes parameters under study (Table 6).

upper arm area using the mode of wave compression with the following parameters:

program (1st point of observation).

(34.4%; P <0,21) (Table 3 and Table 4).

likely (P<0,000001).

analysis.

**Table 4.** Results of IVF in women of the 2nd (controlled) group in relation to the presence or absence of disorders in hemostasis and fibrinolysis

of the pulmonary artery thromboembolia (e.g. in the presence of clinically non-evident iliofemoral thrombosis) and due to the obtained data on the increased content of t-Pa in endotelial vessels of the upper extremities (Pandolfi et al., 1968). That is why we chose pneumatic massaging device PM-01 (Russia) to apply a 7-chamber compression brace in the upper arm area using the mode of wave compression with the following parameters:

94 Enhancing Success of Assisted Reproduction

2.1. Without the required signs of pathology of hemostasis and fibrinolysis

2.2. Without the required signs of pathology of hemostasis and fibrinolysis




observation) and a decrease of the index EAAF less than 11% (on the 1st point of

Received treatment against diseases of hemostasis,

2.2.3. When combined IPC course with heparin

disorders in hemostasis and fibrinolysis

2.2.4. Those in need of treatment, but did not

observation)

observation)

including:

prophylaxis

prophylaxis

receive it

2.2.1. After heparin

Subgroups examined Аbs.

(n=164)

% of total number of women

Impregnation

% of number of pregnant

Аbs. (n=68)

26 15,8 21 30,9

138 84,2 47 69,1

50 30,5 19 27,9

40 24,4 14 20,6

48 29,3 14 20,6

98 59,8 42 61,8

38 23,2 15 22,1

37 22,6 17 25

40 24,4 5 7,3

2.2.2. After IPC course 23 14,0 10 14,7

**Table 4.** Results of IVF in women of the 2nd (controlled) group in relation to the presence or absence of

chambers from 30 to 150 mm. Hg. Art., 45 cycles of compression wave with memory for 30 minutes to maintain the pressure in the cuff chambers from 5 to 90., the pressure of compressed air supplied to the compression performed in a course of 8 sessions (twice a week) with 30-minute cuff device to the left or right hand. The starting point of this therapy was to reduce EAAF index below 11% measured in a number of patients just prior to IVF program (1st point of observation).

Studies have found that the total number of favorable outcomes of IVF in the 2nd (controlled) group was 41.5%, an increase of only 7.1%, compared with those in group 1 (34.4%; P <0,21) (Table 3 and Table 4).

However, please note that 40 patients (subgroup 2.2.4) failed our proposed therapy, although prescribed by the above criteria. If to sum up the outcome of IVF in all samples in the study of women who had indications for treatment but did not receive it for a number of reasons (sub 1.2 and 2.2.4; 154 cases) we indicate positive results in 9.1%, whereas in the treated patients (subgroup 2.2.1, 2.2.2 and 2.2.3, 98 cases) - in 42.9%, or 4.71 times more likely (P<0,000001).

Effect of treatment produced on the dynamics of hemostasis and fibrinolysis during IVF is shown in Table 5. You can see the previous trends in Table 2, but the women in group 2, compared to the 1 st group demonstrated lower intensity of thrombin generation and improvement of fibrinolysis regardless of the outcome of IVF.

D-dimer levels in blood plasma has indicated growing trend - the concentration of this indicator has been consistently higher regardless of the period of the survey in patients with unsuccessful IVF outcome (Tables 2 and 5). However, the value of D-dimer levels was within the range of normal variation or slightly exceeded them, hardly matching the identified changes parameters under study (Table 6).

In this regard, we have not put the emphasis on the results of this test upon the following analysis.

Other risk factors of unsuccessful IVF which did not depend on the characteristics of hemostatic and fibrinolytic had its effect on IVF success (see Section 2, Table 13, 14), as well as the fact of receiving or not receiving therapeutic intervention aimed at reducing the thrombogenic potential and increasing fibrinolytic activity of blood. Calculations and observations in tables 7-12 demonstrate a better pattern in this regard. In particular, it appeared that an approved prescription of low-molecular heparin at high thrombin generation at the 2nd stage of the study contributed to the increase in the incidence of pregnancy in 6.4 times (P<0,0001), isolated IPC course application -in 3.0 times (P<0,007), and the combination of IPC course with heparin prophylaxis - in 6.5-times (P<0,0001) (Table 7).


The Means of Progress in Improving the Results of *in vitro* Fertilization Based on the Identification and Correction of the Pathology of Hemostasis 97

(RRR)

First point of observation

0,55 1,8 0,24 0,23-0,60 0,02-0,22 63

CI 95% (OR)

In need of treatment, and treated (subgroup 2.2.1, 2.2.2 и 2.2.3; n=98)

> Second point of observation

RRR%

Third point of observation

Criteria such as Absolute Risk Reduction (ARR), Relative Risk (RR), Relative Risk Reduction (RRR), Number Needed to Treat (NNT), Confidence Interval (CI) were determined for

ARR NNT OR CI 95%

Heparin Prophylaxis 0,27 3,7 0,22 0,52-0,92 0,07-0,69 31 IPC Course 0,31 3,2 0,19 0,44-0,94 0,05-0,65 35

> Third point of observation

307,1±31,8 391,2±25,3\*\* 385,4±22,5\*\* 313,1±19,7 362,8±23,1 341,3±25,6

0,32±0,15 0,34±0,16 0,33±0,15 0,34±0,12 0,48±0,15 0,49±0,14

3,18±2,32 3,22±1,66 3,26±1,75 3,22±1,71 2,76±1,51 2,68±1,67

13,1±3,6 14,2±3,9 15,4±3,8\*\* 12,2±4,4 10,1±4,5 9,2±3,4

ETP, nM/min 1459,4±85,1 1912,5±108,6\*\* 1872,8±85,1\*\* 1490,6±84,1 1729,8±89,5 1566,4±72,7

EAAF index, % 10,0±3,2 10,5±4,3\*\* 10,1±4,1\*\* 10,5±3,5 17,3±4,4 18,2±4,2

**Table 9.** The dynamics of hemostasis and fibrinolysis (M ± SD) in women in a cycle of IVF when

The choice was made towards absence of pregnancy after conducted treatment as the negative outcome of IVF. The control group included 154 women who had revealed violations of blood coagulation and fibrinolysis and did not receive treatment (subgroups 1.2 and 2.2.4). The intervention group had patients who received one of three therapies

**Table 8.** The effectiveness of different methods of therapy in women in a cycle of IVF

it (subgroup 1.2 и 2.2.4; n=154)

Second point of observation

Indication In need of treatment, but did not receive

First point of observation

indicated for the correction of hemostasis (n = 138), t - test

further evaluation of the effectiveness of the treatment (Table 8).

Modality Indication

Heparin prophylaxis combined with IPC

course

Peack

un/ml

un/ml

min

thrombin, nM/l

t-PA, activity,

PAI-1, activity,

Clot lysis time,

**Table 5.** The dynamics of hemostasis and fibrinolysis (M ± SD) in women of second (controlled) group (n = 164), t - test


**Table 6.** Pair correlation between the level of D-dimers (by Spearman) and the study of hemostasis and fibrinolysis in different periods of the IVF cycle, regardless of its outcome


**Table 7.** The influence of the methods of correction of hemostatic and fibrinolytic responses to the effectiveness of IVF (with data 1 and 2 stage of the research)

Criteria such as Absolute Risk Reduction (ARR), Relative Risk (RR), Relative Risk Reduction (RRR), Number Needed to Treat (NNT), Confidence Interval (CI) were determined for further evaluation of the effectiveness of the treatment (Table 8).


**Table 8.** The effectiveness of different methods of therapy in women in a cycle of IVF

96 Enhancing Success of Assisted Reproduction

Peack thrombin, nM/l

un/ml

un/ml

%

t-PA, activity

PAI-1, activity

EAAF index,

Clot lysis time, min

D-dimers, ng/ml

(n = 164), t - test

First point of observation

Indication At failure in IVF cycle (n=96) At pregnancy (n=68)

Third point of observation

ETP, nM/min 1825,3±96,8\* 1922,1±64,7\* 1785,4±±89,5 1645,6±54,9 1762,1±79,8 1711,2±84,3

342,1±26,3\*\* 381,5±25,7\*\* 364,4±24,3\*\* 310,7±27,4 329,1±29,3 326,4±25,7

0,35±0,14 0,51±0,15 0,48±0,13 0,35±0,15 0,47±0,16 0,44±0,14

3,55±1,75 2,64±1,91 2,32±1,58 3,48±2,11 1,95±0,75 1,86±0,57

9,9±4,28 19,3±3,88\* 20,6±4,53\* 10,0±3,97 24,1±4,39 23,6±4,77

15,5±3,65 12,3±3,86 11,4±4,04 13,4±3,85 11,8±3,85 10,1±3,11

236,4±26,2\* 258,6±25,1\* 305,6±28,5\* 194,7±32,4 233,4±24,5 211,7±28,6

**Table 5.** The dynamics of hemostasis and fibrinolysis (M ± SD) in women of second (controlled) group

**Table 6.** Pair correlation between the level of D-dimers (by Spearman) and the study of hemostasis and

not receive it (sub-1.2 and 2.2.4; n = 154)

1. Heparin Prophylaxis 64 4 6,2 38 15 39,5 2. IPC course 48 7 14,6 23 10 43,5 3. Combined effect 42 3 7,1 37 17 45,9 **Table 7.** The influence of the methods of correction of hemostatic and fibrinolytic responses to the

Abs. Became

Indication Rank correlation P value ETP, nM/min 0,09 0,017 Peack thrombin, nM/l 0,125 0,002 t-PA, activity, un/ml 0,118 0,0003 PAI-1, activity, un/ml 0,124 0,0004 EAAF index, % 0,107 0,0006 Clot lysis time, min 0,111 0,0005

fibrinolysis in different periods of the IVF cycle, regardless of its outcome

Modality In need of treatment, but did

effectiveness of IVF (with data 1 and 2 stage of the research)

First point of observation

Second point of observation

In need of treatment, and treated (sub 2.2.1, 2.2.2 and 2.2.3; n = 98)

pregnant %

pregnant % Abs. Became

Third point of observation

Second point of observation


**Table 9.** The dynamics of hemostasis and fibrinolysis (M ± SD) in women in a cycle of IVF when indicated for the correction of hemostasis (n = 138), t - test

The choice was made towards absence of pregnancy after conducted treatment as the negative outcome of IVF. The control group included 154 women who had revealed violations of blood coagulation and fibrinolysis and did not receive treatment (subgroups 1.2 and 2.2.4). The intervention group had patients who received one of three therapies

aimed at correcting identified violations in the hemostatic system and hypofibrinolysis (subgroup 2.2.1, 2.2.2, 2.2.3). It was discovered that all of the treatment reduced the risk of a negative outcome of IVF. In particular, in order to prevent one adverse outcome, you need to treat 2 women by the combined treatment option (1.8), using the IPC - 3 women (3.2), and heparin prophylaxis - 4 women (3.7). The relative risk reduction (RRR) in all cases was greater than 25%, which corresponded to clinical effect, and upon combined RRR therapy more than 50%, indicated a pronounced clinical effect.

The Means of Progress in Improving the Results of *in vitro* Fertilization Based on the Identification and Correction of the Pathology of Hemostasis 99

> First point of observation

IPC Course recipients (subgroup 2.2.2.2; n=23)

> Second point of observation

At heparin prophylaxis and IPC course recipients (subgroup 2.2.3; n=37)

> Second point of observation

Third point of observation

Third point of observation

Indication In need of treatment, but did not

First point of observation

event of Table readings for IPC course (n = 71), t – test

Indication In need of treatment, but did not

First point of observation

indicated for combination therapy (n = 79), t – test

Peack thrombin,

t-PA, activity,

PAI-1, activity,

Clot lysis time,

Peack thrombin,

t-PA, activity,

PAI-1, activity,

Clot lysis time,

nM/l

un/ml

un/ml

min

nM/l

un/ml

un/ml

min

receive it (subgroup 1.2.2. и 2.2.4.2; n=48)

> Second point of observation

Third point of observation

314,2±30,3\* 322,4±28,2 327,7±25,7\*\* 294,5±24,4 322,1±31,1 353,3±25,9

0,36±0,14 0,39±0,15 0,37±0,14\* 0,35±0,16 0,51±0,15 0,48±0,15

3,98±1,67 4,11±2,32 4,05±2,54\* 3,55±1,88 2,64±1,06 2,32±1,32

13,8±4,3 14,4±4,6\* 14,8±3,2\*\* 14,3±4,1 11,4±3,7 9,0±3,3

ETP, nM/min 1534,4±87,2\*\* 1575,7±85,6 1589,6±96,4 1415,1±87,7 1562,3±86,1 1632,3±93,8

EAAF index, % 9,0±3,2 9,5±3,6\*\* 9,1±4,0\*\* 9,9±3,2 19,3±3,4 20,6±4,5

**Table 11.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women in the

Third point of observation

322,3±32,4 379,3±29,1 374,5±31,6\*\* 324,7±27,6 371,2±33,8 335,6±30,7

0,37±0,17 0,39±0,15 0,36±0,16 0,31±0,16 0,49±0,15 0,46±0,14

3,64±2,05 4,12±1,77 3,45±1,98 3,02±1,69 2,29±1,14 2,09±0,91

15,4±3,9 13,2±4,2\*\* 15,7±3,4\*\* 13,8±2,3 10,0±3,8 9,1±3,9

ETP, nM/min 1538,6±78,3 1770,4±85,6 1756,6±95,7\*\* 1566,7±86,3 1764,4±95,7 1542,1±81,3

EAAF index, % 10,2±2,9 9,5±3,1\*\* 10,4±3,3\*\* 10,2±2,6 21,4±4,5 22,0±4,3

**Table 12.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women when

Similar calculations were performed in women with hypofibrinolysis as well as with the combination of low fibrinolytic activity with excessive generation of thrombin (Tables 11 and 12). It was found that the isolated effects of IPC in women with original, prior to the IVF

First point of observation

receive it (subgroup 1.2.3 и 2.2.4.3; n=42)

> Second point of observation

Evolution of indicators reflecting defects of hemostatic and fibrinolytic reactions in patients in need of therapeutic intervention are shown in Table 9. Obviously, undertaken treatment has a beneficial effect on the rate of thrombin generation and fibrinolysis, and the index EAAF which reflects fibrinolysis-activation ability of the vascular wall indicated the increase in 2 times.

We also made separate calculations of laboratory parameters in women with high thrombin generation in need of heparin prophylaxis (Table 10). As a result, it was found that low molecular weight heparin with a mid-cycle IVF significantly reduces the generation of thrombin. In particular, the background rate nadroparin ETP between the 2nd and 3rd observation points decreased by 18.1%, compared to 3.6% in women who did not receive anticoagulant. The similar dynamics had Peack thrombin, which decreased, respectively, by 13.2% and 1.8%.


**Table 10.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women in the presence of indications for heparin prophylaxis (n = 102), t – test

It should be noted that the indicators of fibrinolytic activity has not changed and remained stable without regard to heparin and duration of the study.


in 2 times.

13.2% and 1.8%.

Peack

un/ml

un/ml

min

thrombin, nM/l

t-PA, activity,

PAI-1, activity,

Clot lysis time,

more than 50%, indicated a pronounced clinical effect.

Indication In need of treatment, but did not receive

presence of indications for heparin prophylaxis (n = 102), t – test

stable without regard to heparin and duration of the study.

First point of observation

it (subgroup 1.2.1. и 2.2.4.1; n=64)

Second point of observation

aimed at correcting identified violations in the hemostatic system and hypofibrinolysis (subgroup 2.2.1, 2.2.2, 2.2.3). It was discovered that all of the treatment reduced the risk of a negative outcome of IVF. In particular, in order to prevent one adverse outcome, you need to treat 2 women by the combined treatment option (1.8), using the IPC - 3 women (3.2), and heparin prophylaxis - 4 women (3.7). The relative risk reduction (RRR) in all cases was greater than 25%, which corresponded to clinical effect, and upon combined RRR therapy

Evolution of indicators reflecting defects of hemostatic and fibrinolytic reactions in patients in need of therapeutic intervention are shown in Table 9. Obviously, undertaken treatment has a beneficial effect on the rate of thrombin generation and fibrinolysis, and the index EAAF which reflects fibrinolysis-activation ability of the vascular wall indicated the increase

We also made separate calculations of laboratory parameters in women with high thrombin generation in need of heparin prophylaxis (Table 10). As a result, it was found that low molecular weight heparin with a mid-cycle IVF significantly reduces the generation of thrombin. In particular, the background rate nadroparin ETP between the 2nd and 3rd observation points decreased by 18.1%, compared to 3.6% in women who did not receive anticoagulant. The similar dynamics had Peack thrombin, which decreased, respectively, by

> Third point of observation

310,1±23,1 382,4±19,5 375,6±25,2\*\* 321,2±22,3 386,3±23,5 335,2±20,2

0,30±0,16 0,33±0,15 0,31±0,15 0,33±0,12 0,41±0,16 0,42±0,17

2,40±1,13 2,50±1,22 2,44±1,98 2,84±1,45 3,61±1,75 3,50±1,71

9,4±3,0 8,7±3,3 10,1±3,5 8,4±3,7 8,7±2,8 9,7±3,2

ETP, nM/min 1461,2±81,6 1849,3±89,2 1782,4±93,5\*\* 1489,5±85,5 1861,2±94,4 1524,6±88,9

EAAF index, % 12,5±3,1 13,2±4,2 12,7±3,6 11,62±3,2 11,35±4,2 12,0±3,9

**Table 10.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women in the

It should be noted that the indicators of fibrinolytic activity has not changed and remained

At heparin prophylaxis (subgroup 2.2.1; n=38)

> Second point of observation

Third point of observation

First point of observation

**Table 11.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women in the event of Table readings for IPC course (n = 71), t – test


**Table 12.** The dynamics of hemostasis and fibrinolysis (M ± SD) in the second group of women when indicated for combination therapy (n = 79), t – test

Similar calculations were performed in women with hypofibrinolysis as well as with the combination of low fibrinolytic activity with excessive generation of thrombin (Tables 11 and 12). It was found that the isolated effects of IPC in women with original, prior to the IVF cycle hypofibrinolysis indicated a sharp increase in EAAF index combined with the decrease in CLT. Interestingly, vases compression led to the significant increase of t-PA activity as well as to the reduction of PAI-1activity at the end of the IVF cycle. It was also discovered that the application of IPC led to increased thrombin generation which Peack thrombin factor clearly demonstrated.

The Means of Progress in Improving the Results of *in vitro* Fertilization Based on the Identification and Correction of the Pathology of Hemostasis 101

*5.2.3. Comparative analysis of the prognostic value of a number of factors contributing to* 

This section has recorded and compared the effect of risk factors in the failure of IVF in 1st (observation) group and women of (2nd) group. We studied a wide range of adverse prognostic factors which are well-known in Reproduction and discussed in this publication: markers of thrombogenic risk and blood fibrinolytic activity reduction as well as hyperhomocysteinemia, thrombogenic mutations and polymorphisms carriers, presence of an inflammatory response (Bates et al., 2008; Coulam & Jeyendran, 2009b; Heit, 2007; Qublan & Eid, 2006), "0" blood type negative factor [Canonico et al., 2008; Ohira et al., 2007.) Assessing the reasons for the failure of pregnancy in IVF cycles in 163 patients of the 1st (observation) group based on the analysis of the odds ratio (OR), 9 out of 27 (33.3% ) factors became the most important adverse factors or symptoms to be rated as fairly significant (Table 13). Importantly, indicators reflecting increased thrombin generation and inhibition of fibrinolytic reactions, respectively, 2nd and 3d entered the adverse factors as well. Hypo fibrinolysis factors with high reliability proved to be at the 5th and 6th adverse factors ranking. Consequently, in addition to well-known factors listed in Section 2, increased ability to thrombosis, in response to the stress estrogen and inhibition of fibrinolytic reactions are among the leading causes of failure of IVF. It is interesting to note that such a well-known and widely used in clinical practice marker of thrombinemia as high D-dimer plasma levels did not vary in frequency of occurrence in impregnate women at all stages of

Carriage of thrombogenic mutations and polymorphisms were identified in the majority of our patients (71.2%). By the rare mutations - Factor V Leiden and prothrombin in only 4 cases (2.4%), we cannot judge the significance of their influence. However, the combination of polymorphisms MTGFR and PAI-1 was found in a slightly larger percentage of cases with unsuccessful IVF (24.3% vs. 16.0%) to be, however, insignificant. Interestingly, blood type "not 0"did not prove to be protrombogen/unfavorable by nature in our observation as well as a number of variants of virus infection carriers and the manifestations of

The number of factors contributing to the failure of pregnancy in IVF changed dramatically after exposure to therapeutic correction of hemostasis and fibrinolysis, used in the present publication. In accordance with the data in Table 14, traditional reasons for Reproduction are among the leaders: early hyperstimulation, male factor, and others. Hyperhomocysteinemia (OR 3,45; 0,95% CI 1,16-10,2) became one of the hemostatic reasons at the 4th rank to be the result of obvious lack of attention to the problem of metabolic methionine in preparation for IVF protocol. The significance level of manifestation of high thrombin generation shifted from the 2nd and 3rd rank to 8th and 9th rank whereas EAAF index - from 6th to 15th rank to be the further proof of the effectiveness of our methods of applied therapeutic intervention. Please, note that the calculations in this table exclude 40 patients with disorders of hemostasis and fibrinolysis who did not receive treatment for a

*the failure of IVF* 

observation (OR 0,99; 0,95% CI 0,42-2,31 – 21 rank).

inflammation (fibrinosis, leukocytosis).

number of reasons (subgroup 2.2.4).

**Figure 3.** The evolution of laboratory parameters of hemostasis and fibrinolysis in women who require concomitant therapy, but do not receive it (A) during such therapy (B)

Combined application of IPC and low molecular weight heparin produced complex beneficial effect on hemostasis and fibrinolysis to be in correspondence with the maximum increase in the number of IVF successful outcomes (Tables 4, 7, 8 and 12).

In Fig. 3 the dynamics of the main parameters studied in the course of the treatment for the correction of hemostasis and fibrinolysis is highlighted.
