endometrial scratching
TRANSCRIPT
ENDOMETRIAL SCRATCHING AND ART CYCLES AT GHS 2014-15
Ali SmithPublic Health Sciences, Clemson
University
Overview
• Implantation defects account for an estimated 50% of IVF and FET failures 1
• Total number of IVF cycles : 175,962 in US 2
• < 45% result in live birth for women < 35 2
1 Timeva et al., J Reprod Infertil 2014; 15:173-1832 SART.ORG
Recurrent IVF Failure
• Women with recurrent IVF failure had similar ovarian reserve and ovarian responses 1
1 Bord et al., Arch Gynecol Obstet 2015 Ahead of print
Overview
• Endometrial scratching has been proposed as a way to improve IVF pregnancy rates 1
• Theories for improvement include:– Scratching induces decidualization 2
– Healing promotes inflammation necessary for implantation 3
1 Nastri et al., Cochrane Database Syst Rev 20122 Li et al., Curr Opin Obstet Gynecol 2009; 21:236-93 Gnainsky et al., Fert Stert 2010; 120:920-927
Ongoing Pregnancy Rates Remain Unaccountably Poor in IVF
Implantation Failure
• Implantation Window – “Frame Shift”
2 4 6 8 10 2812 14 16 18 2420 22 26
Ovulation
Menses
1
NormalDelayed implantation
Failed implantation
Courtesy of Marc Fritz MD
Implantation Failure
• Causes for frame shift may include:– Luteal phase defect 1
– Endometritits 2
– Adenomyosis 3
– Endometriosis 4
– Mechanical factors (fibroids, polyps, retained POC)
1. Lessey and Fritz, 2. Bouet et al., Fert Stert 2015 Ahead of print3. Tremelien and Russell J Reprod Immunol 2012 93:58-634. Littman et al., Fert Stert 2005; 84:1574-8
Endometrial Scratching
• Endometrial scratching or injury to improve receptivity 1
• First paper by Barash F&S 2003 (doubles pregnancy rate in IVF) 2
• Meta-analysis in 2015 Cochrane Database shows evidence for benefit the month before up to day 7 of embryo transfer month 3
1 Simon and Bellver Review HR 20142 Barash et al., F&S 2003Nastri et al., 2015 Cochrane Database of Systematic Reviews
Potential Mechanisms for Benefit
• Induces decidualization (Li and Hao, 2009)• Induces signficant secretion of cytokines,
growth factors, macrophages, dendritic cells (Gnainsky et al., 2010)
• Effect on endometrial advancement seen in IVF cycles (retarding development) (Lass et al., 1998; Horcajadas et al., 2008)
Simon and Beliver 2015
Objective
To compare IVF and FET success rates in women who have endometrial scratching compared to women who don’t have endometrial scratching
• Scratched in the month prior to IVF while taking birth control pills compared to a group of women also taking birth control pills but were not scratched
Potential Confounders
• Women not scratched may have a better prognosis
• Women not scratched received other treatments (sonohystogram) that might mimic the effect of scratching
128 Scratched60 Not scratched
188 Sub-fertile Women
33 Not Pregnant27 Pregnant 56 Not Pregnant72 Pregnant
Flow Chart
DemographicsCharacteristic No Scratch
(n=60)Scratch(n=128) P value
Mean Age (SD) 35.6±4.9
35.3±4.4 0.64
Mean BMI (SD) 24.8±4.8
25.1±5.6 0.77
Median Parity (range) 0.5±0.78
0.33±0.71 0.18
All Patients: Pregnant vs Not Pregnant
Chi square = .16Pregnant= 99/188 (52.7%)
Not Pregnant= 89/188 (47.3%)
Pregnant
Not Pregnant
84 86 88 90 92 94 96 98 100
Results
scratched Not scratched
Pregnant 72 27
Not Pregnant 56 33
Scratched
Not Scratched
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Pregnant
Not Pregnant
Not Scratched:Pregnant 27/33 = 45%
Scratched:Pregnant 72/128= 56.3%
RESULTS
• Successful Pregnancy in fresh cycles: scratching vs no scratching – p=.54
• Successful pregnancy in frozen cycles: scratching vs no scratching– p=.61
• All patients Pregnant vs Not Pregnant– Chi square = .16
DISCUSSION
• Quality of the program – Our pregnancy rates are higher than national average
• LIMITATIONS– Included all ages in study, older women have less of a
chance of success regardless of scratching or cycle type– Our study was done on birth control pills, which is not
typical of many other studies• STRENGTHS
– Fairly large population (n=188)– The two groups were similar in their demographics
CONCLUSIONS
• Scratching does not have a significant difference in fresh or frozen cycles.
• Scratching might be more effective in a practice that has poor IVF success rates.
Future Directions
1. Reconsider the basis for our high success rates
2. Consider discontinuation of scratching
THANK YOU