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Objective: This meta-analysis aimed to evaluate the effect of granulocyte colony-stimulating factor (G-CSF) on the treatment of
recurrent miscarriage (RM) and recurrent implantation failure (RIF).
Methods: Eligible randomized controlled trials (RCTs) and cohort studies were retrieved from the Web of Science, Cochrane,
and PubMed databases and evaluated using the Jadad scale or Newcastle-Ottawa Scale. Cochran’s Q test and I2 statistics were
used to assess heterogeneity. The effect sizes for clinical pregnancy and abortion rates of patients were pooled as risk ratios (RRs)
and 95% confidence intervals (CI) using RevMan 5.3. Publication bias was assessed using funnel plots.
Results: Thirteen studies (nine RCTs and three cohort studies) involving 1262 participants were included. Compared to the
control/placebo group, the use of G-CSF significantly improved the clinical pregnancy rate [RRs (95% CI) = 1.73 (1.41, 2.12), p
< 0.00001] of RIF patients; Whereas it had no significant impact on their abortion rate [RRs (95% CI) = 1.13 (0.43, 2.95), p = 0.80].
Both subcutaneous and intrauterine injections of G-CSF could improve the clinical pregnancy rate in RIF patients. However,
subcutaneous injection showed a tendency to increase the abortion rate [RRs (95% CI) = 1.98 (0.40, 9.87), p = 0.40], whereas
intrauterine injection showed a tendency to decrease the abortion rate for RIF patients [RRs (95% CI) = 0.93 (0.24, 3.53), p =
0.11]. In addition, G-CSF use had no significant impact on the clinical pregnancy rate of RIF patients in a South American study
[RRs (95% CI) = 1.20 (0.60, 2.38), p = 0.60]. For RM patients, the use of G-CSF showed improved clinical pregnancy rates [RRs
(95% CI) = 1.43 (0.76, 2.70), p = 0.27] and lower abortion rates [RRs (95% CI) = 0.80 (0.46, 1.14), p = 0.44] than control/placebo
group; However, the difference was not significant. Similar results were observed in the subcutaneous, intrauterine injection,
and regions subgroups of RM patients.
Conclusions: This meta-analysis confirmed the benefits of G-CSF in improving the clinical pregnancy rate of RIF patients. No
conclusive evidence supports the link between G-CSF use and increased abortion rate in RIF patients and clarifies the association
of G-CSF use with clinical pregnancy and abortion rates in patients with RM.
Keywords: granulocyte colony-stimulating factor; recurrent miscarriage; recurrent implantation failure; clinical pregnancy rate; abortion
rate
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1934
cal disturbances [10]. RIF and RM can occur separately tients with RM or RIF; (2) Interventions in the studies in-
and simultaneously. Patients who had RIF and RM showed cluded the use of G-CSF; (3) Clinical outcomes included
particularly poor obstetric outcomes [11]. Immune system pregnancy rate and/or abortion rate; (4) Studies involved
imbalance is a cause of RIF and RM. For example, in- efficacy comparison with placebo/control; And (5) random-
creased cytotoxicity and levels of natural killer cells, in- ized clinical trial (RCT) or cohort studies. Single-arm stud-
creased Th1:Th2 cell ratios, presence of various autoanti- ies, non-original studies (reviews, letters, and comments),
bodies, and dysregulated cytokines have been observed in and studies that contained combination drugs in the con-
RIF and RM patients [12–16]. Although there are some trol group were excluded. Notably, only study with the
similarities in the pathogenesis and treatment of RM and most complete information was included when the same
RIF, these two conditions represent different points of re- data were used in multiple studies, and the other studies
productive failure, including infertility, RIF in women un- were excluded.
dergoing in vitro fertilization (IVF), and RM [17].
Granulocyte colony-stimulating factor (G-CSF) is a Data Extraction
growth factor that has gained considerable attention in hu- Relevant data from the included studies were ex-
man reproduction following the initial case series of Gle- tracted, including the name of the first author, year of publi-
icher et al. [18], who demonstrated the beneficial impact of cation, country in which the research was conducted, study
G-CSF in patients diagnosed with a thin endometrium. Sub- design, characteristics of the participants (disease types,
sequently, G-CSF was found to play an important role in numbers, age, number of previous failures, and interven-
improving ovarian function and embryo implantation, pro- tions), and clinical outcomes (frequency and rates of clin-
moting endometrial regeneration, and in the continuation of ical pregnancy and abortion). Data extraction was con-
pregnancy [19,20]. However, the benefits of G-CSF in r the ducted by two independent investigators, and any incon-
treatment of RM and RIF have not been sufficiently proven. formity during this process was addressed through consul-
Several studies have demonstrated the application of G- tation.
CSF in improving implantation and clinical pregnancy rates
[21,22]. In addition, studies have suggested that G-CSF has Quality Assessment
no obvious effectiveness in improving clinical pregnancy Cohort studies were assessed for selection, compara-
or live births [23] and may increase miscarriage rates [24]. bility, exposure, and outcomes using the Newcastle-Ottawa
Meta-analyses have reported positive effects of G-CSF in Scale (NOS) [27], which comprises a maximum score of 9.
improving the rates of implantation and clinical pregnancy Studies with scores >5 were considered to be of high qual-
in RIF patients [25,26]. However, the association between ity. The methodological quality of RCT was assessed using
G-CSF use and miscarriage rate remains unclear. There- the Jadad scale, in which the study was assessed in terms
fore, this study aimed to describe the effects of G-CSF in of whether it was randomized or double-blind, in addition
clinical pregnancy and miscarriage rates in patients with to whether withdrawals and dropouts were mentioned [28].
RIF and RM, based on a meta-analysis of randomized con- The Jadad scale has a maximum score of 7, and the study
trolled trials (RCTs) and cohort studies. was regarded as high quality with a score >4.
Fig. 2. Effect of G-CSF on clinical pregnancy and abortion rates. Forest plots showing the pooled results of G-CSF use on clinical
pregnancy rate (A) and abortion rate (B) of recurrent miscarriage (RM) and recurrent implantation failure (RIF) patients.
1937
Fig. 3. Modes of G-CSF administration on clinical pregnancy and abortion rates among RIF patients. Forest plots showing
the pooled results of G-CSF subcutaneous or intrauterine injection on clinical pregnancy rate (A) and abortion rate (B) of recurrent
implantation failure (RIF) patients.
1938
Fig. 4. Modes of G-CSF administration on clinical pregnancy and abortion rates among RM patients. Forest plots showing
the pooled results of G-CSF subcutaneous or intrauterine injections on clinical pregnancy rate (A) and abortion rate (B) of recurrent
miscarriage (RM) patients.
1939
Fig. 5. Effect of G-CSF administration on clinical pregnancy and abortion rates among RM patients in different regions. Forest
plots showing the pooled results of G-CSF administration on clinical pregnancy rate (A) and abortion rate (B) of recurrent miscarriage
(RM) patients in Europe and West Asia.
1940
Fig. 6. Effect of G-CSF administration on clinical pregnancy and abortion rates for RIF patients in different regions. Forest plots
showing the pooled results of G-CSF administration on clinical pregnancy rate (A) and abortion rate (B) of recurrent implantation failure
(RIF) patients in West Asia, East Asia, South America, and Africa.
1941
Fig. 7. Subgroups by adjusted analysis. Forest plots showing the pooled results of G-CSF administration on clinical pregnancy rate
(A) and abortion rate (B) of recurrent implantation failure (RIF) patients in the adjusted or non-adjusted subgroups.
1942
Table 1. Characteristics of the included studies.
Author Country Study Diagnostic Participants Age (Y) Previous Clinical pregnancies Abortion rate Adjusted factors
(year) design system case vs control case/control failure
case/control
34.9 ± 2.7/
Scarpellini Hungary RCT RM 35 vs 33 ≥4/≥4 G-CSF: 29 (82.8%)/Placebo: 16 G-CSF: 6 (17.2%)/ Placebo: 17 None
33.8 ± 2.9
F. 2009 [29] (48.5%) (51.5%)
37.63 ± 3.97/
Santjohanser Germany cohort RM 49 vs 33 ≥2/≥2 G-CSF: 23 (46.9%)/control: 8 (24.4%) G-CSF: 7 (30.4%)/control: 4 (50%) None
37.61 ± 4.41
C. 2013 [22] study
age, endometrial thickness,
33.5 ± 4.2/ good-quality metaphase II oocyte counts,
Aleyasin A. Iran RCT RIF 56 vs 56 ≥3/≥3 G-CSF: 21 (37.5%)/control: 8 (14.3%) ——
32.4 ± 5.2 number of transferred embryos,
2016 [21]
and anti-Mullerian hormone levels
35.5 ± 4.32/
Davari- Iran RCT RIF 40 vs 40 vs 20 35.3 ± 3.98/ ≥3/≥3 G-CSF: 8 (80%)/Placebo: 4 (80%) G-CSF: 2 (20%)/Placebo: 1 None
Tanha F. 35.4 ± 4.01 /control: 2 (100%) (20%)/control: 0
2016 [33]
32.55 ± 4.61/
Eftekhar M. Iran RCT RIF 45 vs 45 ≥2/≥2 G-CSF: 13 (28.88%)/control: 6 (13.3%) —— None
31.75 ± 5.16
2016 [36]
30.2 ± 4/
Zafardoust Iran RCT RM 23 vs 27 ≥3/≥3 G-CSF: 4 (17.4%)/control: 3 (11.1%) G-CSF: 8 (33%)/control: 10 (37.5%) None
31.6 ± 5
S. 2017 [30]
34.53 ± 5.50/
Arefi S. Iran RCT RIF 32 vs 20 ≥2/≥2 G-CSF: 18 (56.2%)/control: 8 (40%) G-CSF: 2 (6.5%)/control: 1 (5%) None
34.05 ± 6.5
2018 [32]
37.8 ± 3.8/
Dieamant F. Brazil cohort RIF 33 vs 33 ≥2/≥2 G-CSF: 12 (36.4%)/control: 10 (30.3%) G-CSF: 3 (25.0%)/control: 1 (9.0%) None
37.8 ± 3.9
2019 [37] study
Eapen A. Britain RCT RM 76 vs 74 29∼34/26∼33 ≥3/≥3 rhG-CSF: 67 (88.2%)/Placebo: 69 rhG-CSF: 28 (36.8%)/Placebo: 25 None
2019 [23] (93.2%) (33.8%)
32.09 ± 4.21/
Huang P. China RCT RIF 52 vs 52 vs 59 32.07 ± 4.36/ ≥2/≥2 G-CSF: 28 (53.84%)/Placebo: 28 G-CSF: 2 (7.14%)/Placebo: 12 None
2020 [34] 32.40 ± 4.29 (53.84%)/control: 21 (35.60%) (42.86%)/control: 9 (42.85%)
34.61 ± 4.77/
Kalem Ziya. Korea RCT RIF 82 vs 75 —— G-CSF: 31 (37.8%)/Placebo: 20 G-CSF: 7 (8.5%)/Placebo: 2 (2.7%) None
34.92 ± 5.60
2020 [35] (26.7%)
32.8 ± 4.2/
Zeyneloglu Turkey cohort RIF 38 vs 34 ≥2/≥2 G-CSF: 20 (52.6%)/control: 8 (23.5%) —— None
34.2 ± 4.2
H. B. 2020 study
[38]
35.1 ± 5.04/
Torky H. Egypt RCT RIF 50 vs 50 ≥3/≥3 G-CSF: 28 (56%)/Placebo: 11 (22.9%) G-CSF: 1 (2%)/Placebo: 2 (4.2%) None
35.17 ± 4.23
2022 [31]
Note: RCT, randomized clinical trial; RIF, repetitive implantation failure; RM, recurrent miscarriage; G-CSF, granulocyte colony-stimulating factor; rhG-CSF, recombinant human granulocyte colony-
stimulating factor; hGM-CSF, human granulocyte/macrophage colony-stimulating factor.
1943
ing embryo implantation and ovarian function, promoting cal treatment (method of administration, dosage, and medi-
endometrial regeneration, and in the continuation of preg- cation time). A meta-analysis demonstrated that subcuta-
nancy [19,20]. neous or intrauterine infusion could improve the clinical
pregnancy rate among RIF patients [25]. Zeyneloglu et
Based on a multicenter RCT, Aleyasin et al. [21]
al. [38] compared three routes of G-CSF administration
indicated that subcutaneous G-CSF administration before
and found that intrauterine combined with subcutaneous
implantation could significantly improve the implantation
administration before ovulation resulted in better clinical
(18% vs. 7.2%), clinical pregnancy (37.5% vs. 14.3%),
outcomes than intrauterine or subcutaneous administration
and chemical pregnancy rates (44.6% vs. 19.6%) for RIF
alone for RIF patients. It has been suggested that G-CSF re-
patients undergoing IVF; In addition, the associations were
ceptors are found in various tissues and cell types, and the
also significant after adjustment for multiple possible in-
systematic application of G-CSF might trigger more side ef-
fluencing factors, including endometrial thickness, number
fects in comparison with its local application. Additionally,
of good-quality oocytes and transferred embryos, age, and
intrauterine administration of G-CSF might be easier and
anti-Mullerian hormone levels. Kalem et al. [35] demon-
safer for patients due to the direct effect on the endometrium
strated that intrauterine infusion of G-CSF had no obvious
via this administration route.
impact on endometrial thickness, pregnancy, and live birth
rates in RIF patients with a normal endometrium. Our cur- For RM patients, the pooled results indicated that G-
rent meta-analysis suggests that G-CSF use significantly CSF use showed a trend toward improved clinical preg-
improved the clinical pregnancy rate of RIF patients but did nancy rates (RRs = 1.43) and lower abortion rates (RRs =
not increase the abortion rate. Similar results have been re- 0.80); However, the difference was not significant. San-
ported previously [25,26]. Although G-CSF showed po- tjohanser et al. [22] suggested that G-CSF application
tential benefits in the improvement of clinical outcomes for RM patients undergoing ART could improve the preg-
in RIF patients, there is no consensus on a standard clini- nancy (47% vs. 27%/24%) and live birth rates (32%
1945
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