What is endometrial stimulation?

Successful pregnancy requires implantation of the embryo into the endometrium. Failure to achieve this reproductive phenomenon of embryo endometrial adhesion results in menstruation. In an IVF cycle we can predict the quality of embryo and its chances of succeeding in the implantation process. A mismatch in development of embryo and endometrium can result in failure to achieve pregnancy. At times very good embryos fail to implant due to endometrial rejection. Endometrial scratch or stimulation may help these cases of repeated implantation failure. 

How does endometrial scratch help?

Scratching of endometrium disrupts the continuity and causes an injury. This injury leads to release of various factors of inflammation. It may also activate the gene responsible for endometrial receptivity. Various molecules like prostaglandins, cytokines, integrins, and leukemia inhibitory factors are responsible for implantation. After endometrial stimulation these molecules are start inducing growth and receptivity.

What is the cost of this procedure?

If you are cooperative this test takes minimum time and cost. Your doctor can perform this procedure on an outpatient basis. It will cost you 2000 rupees and some medications. If your doctor advises you to carry our procedure under anesthesia, it will be costly. Usually elderly and anxious women will need anesthesia. In these circumstances the cost may go up to 20000 INR.

What is endometrial receptivity disorder?

Implantation is the deciding step in successful pregnancy and requires a receptive endometrium. In a small number of cases an embryo doesn’t  implant because of a hostile endometrial lining. In other words, the endometrium of the uterus does not provide  the right environment for the embryo. This failed embryonic implantation is due to endometrial receptivity disorder. Endometrial receptivity depends on the signals from various chemical messengers. Dysregulation of these molecules causes implantation failure. Thickness of endometrium, immunity status, adhesive molecules all play a role in receptivity disorder. Endometrial stimulation or scratching may improve these factors.

Endometrial scratch Can help IVF cycles

In the IVF cycle your doctor will hyperstimulate the ovaries to retrieve multiple eggs. In this process a lot of estrogen hormone is released by the ovaries. Due to this higher level of hormone your endometrium grows faster than usual and attains abnormally advanced maturity. This creates asynchrony between embryo and endometrium leading to failure of implantation. Endometrium scratching delays the growth of uterine lining by producing injury. It promotes wound healing by releasing various growth factors. In addition, these factors increase the blood flow to endometrium. Adequate blood flow to endometrium prevents embryo rejection.

Who can undergo endometrial stimulation?

Your doctor may advise endometrial stimulation in the following conditions: 

How do you prepare for endometrial scratch?

Since this test is done as an outpatient procedure and doesn’t require any preparation. You may take a small meal before the process. Don’t panic and keep cool. Your doctor may advise a painkiller 15 mins before putting you in position. If you are very anxious and sensitive to pain, your doctor will prefer light anesthesia and conduct the test in the operation theatre.

Procedure of endometrial scratch

Commonly, endometrial stimulation is useful in patients undergoing IVF treatment. It is a practice of injuring the endometrium in order to achieve better success. This endometrial trauma stimulates the uterine lining to increase the implantation rate.

Endometrial scratch is carried out using a small sterile plastic tube. Nevertheless, this sterile plastic catheter is a useful instrument of endometrial biopsy in suspected cases of cancer. Popularly known as pipelle biopsy, this is a cheap and simple procedure. In addition, this method can be employed without pain or requirement of anesthesia in clinic hours.

Instruments For endometrial Scratch

The pipelle catheter is a thin flexible plastic tube. The slenderness of the tube makes it possible to introduce into the uterine cavity through the cervix without pain. Your doctor will move this catheter or rotate it inside the uterine cavity to disrupt the lining tissue. She can obtain tissue for biopsy as well in cases of need. This  procedure is more popular nowadays in fertility treatment. It is a cheap and simple procedure without complications.

What are the modes of endometrial stimulation?

Endometrial scratching enhances uterine receptivity by multiple means:

1. Stimulation of the endometrium at the site of injury causes favourable changes in the local area.This in turn increases factors of implantation for a successful pregnancy.

2. Repair process following scratching and trauma invites cells of inflammation to the site. Various inflammatory  cytokines and growth factors exert a positive effect on implantation. In high concentrations these factors exert a positive outcome in the implantation window.

3. Hyperstimulation of ovaries during IVF treatment causes advanced endometrial maturation. Endometrial stimulation in this cycle may help synchronize embryo development and endometrial preparation.

Who should not undergo endometrial scratch?

  • Women having pelvic infection or repeated UTI
  • Previous cesarean section
  • History of intestinal surgery or infection
  • Stage 4 endometriosis
  • Bilateral hydrosalpinx
  • Pelvic tuberculosis
  • Bleeding disorders
  • Undergoing PGD
  • Contraindication for IVF/ICSI
  • Any diseases of endometrium like fibroids, septum, polyp

Timeline of Implantation process

Successful implantation of the embryo is the rate limiting factor in IVF treatment. This process includes following steps:

  • Implantation process starts on day 5 post fertilization and probably ends on day 10 called implantation window. At this time we can confirm pregnancy with beta HCG test in the blood.
  • The zona pellucida surrounding the blastocyst ruptures on day 4 post fertilisation.
  • This phenomenon is also known as hatching. 
  •  Adhesion of the blastocyst to the endometrium is the next most important step.
  • The embryo starts developing and burying into the endometrium in the next few days.

What are the methods of evaluating endometrial receptivity?

In IVF treatment even the best quality embryos fail to implant. Receptivity of endometrium is important in controlling implantation. Both invasive and non invasive methods are available to evaluate endometrium.

  • Non invasive methods: Ultrasound on endometrium to detect thickness, pattern and sub endometrial blood flow. 3D ultrasound for calculating endometrial volume
  • Invasive method: endometrial receptivity array

Can I undergo this procedure before natural pregnancy or IUI cycles?

Endometrial scratching in the early phases of the menstrual cycle can enhance receptivity. In the follicular phase of the same cycle of IUI treatment it increases the chances of clinical pregnancy. Also, in natural conception cycles, it can make endometrium receptive and enhance the rate of pregnancy. 

What are the other options for repeated implantation failure?

Repeated implantation failure is a condition where a woman undergoing IVF treatment fails at least three times in spite of quality embryos. It is a condition of concern to fertility specialists worldwide. Endometrial tolerance to the embryos is an important factor in the treatment cycle. Defects in receptivity contribute to repeated implantation failure. Low receptivity can be due to thin endometrium, decreased blood flow, reduced regulatory molecules and fewer receptors like pinopods.

Therapies currently used for patients of RIF to enhance endometrial receptivity.

  • Higher doses of estrogen, longer period of endometrial stimulation.
  • Low molecular weight heparin
  • Aspirin
  • Vitamin E
  • Stem Cells and Granulocyte Colony-Stimulating Factor
  • (G-CSF)
  • Growth Hormone (Gn),
  • Biofeedback (BF)
  • Platelet-rich plasma (PRP)
  • Traditional Chinese Medicine (TCMs) derived from placenta
  • Acupuncture

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