The Role of the Endometrial Microbiome in Embryo Implantation and Recurrent Implantation Failure

The expected prevalence of recurrent implantation failures (RIF) is reported to be 15%. Addressing infertility in individuals with RIF is a subject of great significance within the field of reproductive medicine (Busnelli et al., 2020). Successful implantation of the embryo necessitates a harmonious interaction between the embryo and the endometrium. This technique is characterized by its intricate nature and necessitates the active cooperation of the individuals involved. The inability of an embryo to successfully implant can be attributed to factors associated with either the embryo itself or the uterine environment (Salamonsen et al., 2016). The implantation process is shrouded in considerable uncertainty and lacks comprehensive understanding. RIF poses challenges for both patients and healthcare providers (Andrew and White, 2000). In addition to the financial burden associated with costly treatments and procedures, this situation causes significant emotional distress for couples. Recent studies have focused on investigating the uterine microbiome and its impact on the success of implantation. Microbiota refers to a collection of microorganisms that inhabit a specific ecological niche within the human body and have a symbiotic relationship with the host organism (Perez-Muñoz et al., 2017, D’Ippolito et al., 2018, Benner et al., 2018, Walther-António et al., 2016). The occurrence of implantation failure has been found to be associated with the presence of pathogenic endometrial microbiome (Fig. 1) (Moreno et al., 2016). The modified population of Lactobacillus has the potential to result in compromised endometrial receptivity (Bracewell‐Milnes et al., 2018). According to existing literature, a healthy endometrial microbiome is anticipated to have a reduced biomass and induce a mild activation of the local immune system, hence promoting the process of normal tissue remodeling (Einenkel et al., 2019). Furthermore, it is hypothesized that the production of metabolites by this entity may contribute to the support of the endometrium. Simultaneously, it is believed to inhibit the migration of pathogens by spatial antagonization (Benner et al., 2018). On the contrary, a dysbiotic microbiota is distinguished by an excessive presence and robust immunological stimulation, resulting in localized damaging consequences (Einenkel et al., 2019). Currently, there is a lack of clarity regarding the potential negative effects of opportunistic microorganisms found in the endometrium on the process of implantation. Furthermore, the specific composition of the uterine microbiota that is considered normal, as well as the composition associated with dysbiosis that may have a detrimental impact on implantation, remains uncertain. Additionally, it is unclear where the threshold lies between normalcy and pathology in terms of the quantitative and qualitative balance of microorganisms in the endometrium (Chen et al., 2021, Sezer et al., 2022, Diaz-Martínez et al., 2021, Toson et al., 2022). The investigation of the microbiome's role in human health and disease, specifically its impact on the outcomes of human reproduction, is currently being elucidated (Tomaiuolo et al., 2020). The knowledge pertaining to the microbiome in the reproductive tract is currently experiencing a rapid expansion due to advancements in technologies and methodologies for sampling and analyzing. According to previous research (Al-Nasiry et al., 2020), this growth is unparalleled. As we learn more about reproductive tract dysbiosis, we may be able to better treat it without using broad-spectrum, non-selective antibiotics, which has been the main treatment method in the past (Tomaiuolo et al., 2020). This study aims to conduct a comprehensive assessment of existing studies that investigate the role of the composition of the endometrial microbiome in RIF.

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