Anti-Adhesive Podocalyxin Expression Is Disrupted in Recurrent Implantation Failure

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting study looking at two different molecules important for embryo implantation.  There are several concerns that limit enthusiasm for the current manuscript.

1. 24 RIF patients is a low number for a clinical study. 

2. Many patients will fail to implant after 2 embryo transfers.   Generally, we consider RIF only after 3 transfers of euploid embryos.  was PGT performed?

3. What is "ascites conception cycles"?

4. English needs extensive editing.

4. Please expand on and cite the extensive literature that shows the role of HOXA10 in embryo implantation.

Comments on the Quality of English Language

Needs extensive editing for proper english

Author Response

Reply for reviewer 1

Q1. 24 RIF patients is a low number for a clinical study. 

R1: In the sample size estimation based on the study of Yang et al. (Yang Y, Chen X, Saravelos SH, Liu Y, Huang J, Zhang J, Li TC. HOXA-10 and E-cadherin expression in the endometrium of women with recurrent implantation failure and recurrent miscarriage. Fertil Steril. 2017;107(1):136-143.e2), the minimum number of samples required to compare 3 independent groups was determined as 22 for each group when the effect size f=0.54, α=0.01 and power (1-β)=90% were accepted. Sample size estimation was made with G*Power version 3.1.9.4 (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). The higher the number of cases, the rarer the differences can be detected. However, the number 24 also provides sufficient power for statistical analysis.

Q2. Many patients will fail to implant after 2 embryo transfers.   Generally, we consider RIF only after 3 transfers of euploid embryos.  was PGT performed?

R2: PGT was not performed. Failure to conceive despite three or more embryo transfers was accepted as RIF. The definition of RIF was expressed incorrectly in the text. We are sorry for the misunderstanding. On the other hand, there is no general consensus regarding the definition of RIF. Some authors accept two and some accept three unsuccessful embryo transfers as RIF. We accepted three unsuccessful cycles as RIF (Polanski LT, Baumgarten MN, Quenby S, Brosens J, Campbell BK, Raine-Fenning NJ. What exactly do we mean by 'recurrent implantation failure'? A systematic review and opinion. Reprod Biomed Online 2014; 28: 409-23.).

Q3. What is "ascites conception cycles"?

R3: The word assist was misspelled as ascites. The necessary correction was made as follows “unsuccessful assisted pregnancy cycles

Q4. English needs extensive editing.

R4: The entire article was extensively edited using the Paperpal program. Scientific revision was highlighted in yellow and grammar revision was highlighted in green.

Q5. Please expand on and cite the extensive literature that shows the role of HOXA10 in embryo implantation.

R5: Detailed information about HOXA10 and implantation was given in the introduction section.

PS: Introduction, methods, results sections have been rearranged. Conclusions section were supported by the results. If additional suggestions and corrections are requested, we can do it again and carefully.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The study is devoted to the prognostic assessment of anti-adhesive protein in RIF.

1)      Abstract.

-          Line 15, 89 - It would have been better if the UEI group had been called comparative rather than control.

2)      Results.

– Line 111. Please correct "Endometriaal "(double a).

– Figure 1. Please explain the abbreviation "TIB". Figure 1 shows the TIB, and the explanation for the figure shows the RIF.

Author Response

Reply for Reviewer 2

Q1: Line 15, 89 It would have been better if the UEI group had been called comparative rather than control.

R1: The UEI group was changed to the comparative group.

Q2– Line 111. Please correct "Endometriaal "(double a).

R2: It was corrected.

Q3– Figure 1. Please explain the abbreviation "TIB". Figure 1 shows the TIB, and the explanation for the figure shows the RIF.

R3: The word TIB is the Turkish word for RIF. It was written by mistake and has been corrected. We apologize for the inappropriateness.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have not sufficiently addressed the concerns.  Additional justification and references are needed.

Comments on the Quality of English Language

Improved but still needs editing.

Author Response

The requested changes were made. Although not many revisions were needed, the work as a whole was improved.

We hope that it will be accepted and published in this form.

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is substantially improved with the extensive editing that has been done.

I would like to see a clear discussion of the limitations that include sample size, power, and lack of PGT-A to exclude embryo factors.

The clinical relevance should also be justified by references to human studies on PDX and HOXA10 in reproduction.  Mouse references are important but there has been much done to examine the role of these molecules in the human that would help to justify this work and provide context. 

Author Response

The changes requested by you were made to the text and highlighted in green. The only in-press article showing the relationship between PDX and HOXA10 was cited. The study design is the most comprehensive in its current form.