Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination

Effect of endometrial injury on pregnancy outcomes in infertile women undergoing intrauterine insemination

Objective

One of the most common treatments for infertility is intrauterine insemination (II). The objective of this study was to determine the effect of endometrial injury on pregnancy outcomes in unexplained infertility in women undergoing II.

Materials and Methods

In this randomized clinical trial, 122 women with unexplained infertility who were referred to Shariati Hospital from 2018 to 2020 were enrolled. They underwent ovulation induction using letrozole and gonadotropins. On day 9 of stimulation, they were randomly assigned to two similar groups of the same size. The first group underwent endometrial local injury by pipelle endometrial sampling, and the second group (control group) received no intervention. Only 1 II cycle was performed for each patient. Patients with negative pregnancy outcomes were followed up for 3 months. Endometrial thickness, dominant follicle count, chemical and clinical pregnancy rate, miscarriage rate, and spontaneous pregnancy rate after the II cycle were compared between the two groups.

Results

Endometrial thickness, dominant follicle count, chemical and clinical pregnancy rate, and miscarriage rate in the same II cycle were not different between the two groups (p>0.05). However, the spontaneous pregnancy rate after the II cycle was significantly higher in the endometrial injury group (p=0.02).

Conclusion

Endometrial injury increases pregnancy rates in later cycles but not in the same II cycle.

Evaluation of the effect of endometrial scratch by hysteroscopic scissors on frozen embryo transfer outcomes: A historical cohort study

Background

Endometrial scratch (ES) has been suggested to improve assisted reproductive techniques success rates by investigating implantation failure.

Objective

In this study, we evaluated the effect of ES on the outcomes of frozen embryo transfer (FET) in women with at least 2 failed embryo transfer cycles.

Materials and Methods

In this historical cohort study, medical data of 236 infertile women who underwent in-vitro fertilization-FET at Ebne-sina Infertility Center, Tehran, Iran, from January 2015-December 2021 was extracted from their medical records. Based on having ES before FET, they were assigned to either the scratch (n = 118) or the no-scratch group (n = 118). We compared these groups regarding pregnancy rates and outcomes.

Results

The demographic characteristics were similar in both groups regarding weight, body mass index, the number of previous embryo transfers, and the duration of infertility. However, the scratch group had a slightly higher mean age (32.31 vs. 29.96 yr, p < 0.001). No statistically significant difference was observed between groups regarding pregnancy rate (p = 0.89). No significant association was observed between scratch, infertility duration, the number of previous FET attempts, and the likelihood of pregnancy in a logistic regression model. No major complications were observed.

Conclusion

Hysteroscopic endometrial scratching with scissors probably has no effect on FET outcomes, including pregnancy or live birth rates.

Fertility specialists' views, behavior, and attitudes towards the use of endometrial scratching in Italy

BACKGROUND

Endometrial scratching (ES) or injury is intentional damage to the endometrium performed to improve reproductive outcomes for infertile women desiring pregnancy. Moreover, recent systematic reviews with meta-analyses and randomized controlled trials demonstrated that ES is not effective, data on the safety are limited, and it should not be recommended in clinical practice. The aim of the current study was to assess the view and behavior towards ES among fertility specialists throughout infertility centers in Italy, and the relationship between these views and the attitudes towards the use of ES as an add-on in their commercial setting.

METHODS

Online survey among infertility centers, affiliated to Italian Society of Human Reproduction (SIRU), was performed using a detailed questionnaire including 45 questions with the possibility to give "closed" multi-choice answers for 41 items and "open" answers for 4 items. Online data from the websites of the infertility centers resulting in affiliation with the specialists were also recorded and analyzed. The quality of information about ES given on infertility centers websites was assessed using a scoring matrix including 10 specific questions (scored from 0 to 2 points), and the possible scores ranged from 0 to 13 points ('excellent' if the score was 9 points or more, 'moderate' if the score was between 5 and 8, and 'poor' if it was 4 points or less).

RESULTS

The response rate was of 60.6% (43 questionnaires / 71 infertility SIRU-affiliated centers). All included questionnaires were completed in their entirety. Most physicians (~ 70%) reported to offer ES to less than 10% of their patients. The procedure is mainly performed in the secretory phase (69.2%) using pipelle (61.5%), and usually in medical ambulatory (56.4%) before IVF cycles to improve implantation (71.8%) without drugs administration (e.g., pain drugs, antibiotics, anti-hemorrhagics, or others) before (76.8%) or after (64.1%) the procedure. Only a little proportion of infertility centers included in the analysis proposes formally the ES as an add-on procedure (9.3%), even if, when proposed, the full description of the indications, efficacy, safety, and costs is never addressed. However, the overall information quality of the websites was generally "poor" ranging from 3 to 8 and having a low total score (4.7 ± 1.6; mean ± standard deviation).

CONCLUSIONS

In Italy, ES is a procedure still performed among fertility specialists for improving the implantation rate in IVF patients. Moreover, they have a poor attitude in proposing ES as an add-on in the commercial setting.

Endometrial injury in women undergoing in vitro fertilisation (IVF)

BACKGROUND

Implantation of an embryo within the endometrial cavity is a critical step in the process of in vitro fertilisation (IVF). Previous research has suggested that endometrial injury (also known as endometrial scratching), defined as intentional damage to the endometrium, can increase the chance of pregnancy in women undergoing IVF.

OBJECTIVES

To assess the effectiveness and safety of endometrial injury performed before embryo transfer in women undergoing in vitro fertilisation (IVF) including intracytoplasmic sperm injection (ICSI) and frozen embryo transfer.

SEARCH METHODS

In June 2020 we searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, LILACS, DARE and two trial registries. We also checked the reference sections of relevant studies and contacted experts in the field for any additional trials.

SELECTION CRITERIA

Randomised controlled trials comparing intentional endometrial injury before embryo transfer in women undergoing IVF, versus no intervention or a sham procedure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two independent review authors screened studies, evaluated risk of bias and assessed the certainty of the evidence by using GRADE (Grading of Recommendation, Assessment, Development and Evaluation) criteria. We contacted and corresponded with study investigators as required. Due to the high risk of bias associated with many of the studies, the primary analyses of all review outcomes were restricted to studies at a low risk of bias for selection bias and other bias. Sensitivity analysis was then performed including all studies. The primary review outcomes were live birth and miscarriage.

MAIN RESULTS

Endometrial injury versus control (no procedure or a sham procedure) A total of 37 studies (8786 women) were included in this comparison. Most studies performed endometrial injury by pipelle biopsy in the luteal phase of the cycle before the IVF cycle. The primary analysis was restricted to studies at low risk of bias, and included eight studies. The effect of endometrial injury on live birth is unclear as the result is consistent with no effect, or a small reduction, or an improvement (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.98 to 1.28; participants = 4402; studies = 8; I² = 15%, moderate-certainty evidence). This suggests that if the chance of live birth with IVF is usually 27%, then the chance when using endometrial injury would be somewhere between < 27% and 32%. Similarly, the effect of endometrial injury on clinical pregnancy is unclear (OR 1.08, 95% CI 0.95 to 1.23; participants = 4402; studies = 8; I² = 0%, moderate-certainty evidence). This suggests that if the chance of clinical pregnancy from IVF is normally 32%, then the chance when using endometrial injury before IVF is between 31% and 37%. When all studies were included in the sensitivity analysis, we were unable to conduct meta-analysis for the outcomes of live birth and clinical pregnancy due to high risk of bias and statistical heterogeneity. Endometrial injury probably results in little to no difference in chance of miscarriage (OR 0.88, 95% CI 0.68 to 1.13; participants = 4402; studies = 8; I² = 0%, moderate-certainty evidence), and this result was similar in the sensitivity analysis that included all studies. The result suggests that if the chance of miscarriage with IVF is usually 6.0%, then when using endometrial injury it would be somewhere between 4.2% and 6.8%. Endometrial injury was associated with mild to moderate pain (approximately 4 out of 10), and was generally associated with some minimal bleeding. The evidence was downgraded for imprecision due to wide confidence intervals and therefore all primary analyses were graded as moderate certainty. Higher versus lower degree of injury Only one small study was included in this comparison (participants = 129), which compared endometrial injury using two different instruments in the cycle prior to the IVF cycle: a pipelle catheter and a Shepard catheter. This trial was excluded from the primary analysis due to risk of bias. In the sensitivity analysis, all outcomes reported for this study were graded as very-low certainty due to risk of bias, and as such we were not able to interpret the study results.

AUTHORS' CONCLUSIONS

The effect of endometrial injury on live birth and clinical pregnancy among women undergoing IVF is unclear. The results of the meta-analyses are consistent with an increased chance, no effect and a small reduction in these outcomes. We are therefore uncertain whether endometrial injury improves the chance of live birth or clinical pregnancy in women undergoing IVF. Endometrial injury does not appear to affect the chance of miscarriage. It is a somewhat painful procedure associated with a small amount of bleeding. In conclusion, current evidence does not support the routine use of endometrial injury for women undergoing IVF.