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