Fertility

Including but not limited to:

  • Recurrent pregnancy loss (RPL)
  • Recurrent implantation failure (RIF)

Evolving Information

The following medical conditions have been brought forward as evolving, showing some benefit in limited explicit circumstances whereas historically recommendations have been Do Not Use. The decision to use IG or not use IG in this setting, should be on a case-by-case basis utilizing the following criteria and dosing recommendations adopted with permission from Quebec INESSS and McGill University Health Centre – Reproductive Centre. If clinical effectiveness has not been achieved, IG should be discontinued. 

Order Number: O2-RPL and O3-RIF

RecommendationsOntario acknowledges there is some evidence to support the use of IG in the very specific setting of Recurrent Pregnancy Loss and Recurrent Implantation Failure. The McGill criteria, as indicated below, must be met to be considered for IVIG or SCIG. The request must be received from a Reproductive Specialty Clinic/Physician for approval consideration. 
 
Qualifying Criteria
Patients must fulfill ALL criteria in 1 and 4 with either medical condition in 2 or 3.
  1. General (all conditions must be met)
    • BMI < 35
    • Age: < 42 (or ≤45 if using oocyte donation)
    • Non-smoking
    • Absence of contraindication to IVIg treatment &
     
    AND

  2. Recurrent pregnancy loss (must meet one criteria)

    • >3 consecutive pregnancy losses before 24 weeks AND ≥ 1 pregnancy failure with immunomodulation (low molecular weight heparin (LMWH), steroids, hydroxychloroquine) or
    • 3 consecutive pregnancy losses with contraindication to immunomodulation

    OR

  3. Recurrent implantation failure (must meet one criteria)
    • > 3 consecutive failed embryo transfers with good quality embryos (with ≥ 2 good quality euploid blastocysts) or
    • Failed at least one embryo transfer with immunomodulation treatment (LMWH, steroids, Matrice Lab® recommendations) or contra-indications to corticosteroid therapy

    AND

  4. Negative work-up for usual causes (all conditions must be met)
    • Normal Uterine cavity
    • Normal parental karyotype (when applicable)
    • No coagulopathy OR previous failure with coagulopathy appropriate treatment
    • No endocrinopathy OR previous failure with endocrinopathy appropriate treatment
Dose/Frequency of AdministrationRECURRENT PREGNANCY LOSS -The dose can be adjusted or repeated according to the individual clinical response. 

Before pregnancy:
IVIG: 0.4-0.6 g/kg every 3 months for a maximum of 6 months
SCIG: 0.1-0.2g/kg a week for a maximum of 6 months 

During pregnancy:
IVIG: 0.4-0.6 g/kg a month up to the 20th week of pregnancy
SCIG: 0.1-0.2g/kg a week up to 20th week of pregnancy 

Review Criteria:
  • RPL – every 3 months
  • In pregnancy- at regular pregnancy follow ups
If no benefit is observed in terms of the patient’s clinical status during the medical reassessment, the therapy should be adjusted or discontinued. 

REPEATED IMPLANTATION FAILURE
IVIG: 0.4-0.6 g/kg once, 3 to 5 days before the embryo transfer
No SCIG recommendations 

Process to obtain IG for RPL and RIF
Reproductive clinic/prescriber contacts local Transfusion Medicine (TM) physician regarding approval, submitting McGill qualifying criteria to TM physician. If the TM physician approves, reproductive clinic faxes the MOH IG or SCIG request form using “OTHER” indication including order number, date and name of TM physician approval, to local TM laboratory and can contact patient support program if SCIG to be used.