CONTEXT: Dyslipidemia adversely affects reproduction outcomes
however, its relation with repeated implantation failure (RIF) remains unclear. OBJECTIVE: This study aims to analyze the impact of dyslipidemia on assisted reproductive technology (ART) outcomes, endometrial transcriptome, and microbiome of RIF women. DESIGN: A retrospective real-world analysis and a prospective study. SETTING: University Clinic. PATIENTS: 6,499 infertile women, including 5,618 non-RIF, and 881 RIF. INTERVENTIONS: Dyslipidemia. MAIN OUTCOME MEASURES: Implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR) were compared in RIF women with or without dyslipidemia. Results of endometrial studies, including RNA-seq-based endometrial receptivity test (ERT), 16S rRNA-based microbiome study, next-generation-sequencing (NGS)-based gene comparison, and bulk RNA-seq deconvolution analysis were analyzed. RESULTS: The prevalence of dyslipidemia in RIF women was significantly higher. In dyslipidemia women, IR, CPR, and LBR were significantly lower, and the prevalence of non-receptive ERT and the presence of endometrial pathogenic bacteria were higher than those of controls. After the personalized treatment, CPR 73.3% and LBR 60.0% were achieved in dyslipidemia women. NGS revealed that 176 differentially expressed genes in the endometrium of RIF women with dyslipidemia compared to those without, suggesting highly enriched in cholesterol and steroid biosynthesis and monocyte differentiation processes. An increased endometrial CD56dim NK cells and macrophage (M)1/M2 ratio with dysregulated immune factors, were found by bulk RNA-seq deconvolution analysis. CONCLUSION: RIF women with dyslipidemia have significantly poorer ART outcomes. In women with dyslipidemia, immune homeostasis was breached in the luteal phase endometrium, implicating a possible immune mechanism for dyslipidemia-related implantation failure.