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Effect of local endometrial injury on pregnancy outcomes in ovum donation cycles
Effect of local endometrial injury on pregnancy outcomes in ovum donation cycles Lena Dain, M.D.,a Kamal Ojha, M.D.,b,c David Bider, M.D.,d Jacob Levron, M.D.,d Viktor Zinchenko, M.D.,e Sharon Walster,c and Martha Dirnfeld, M.D.a a
Division of Fertility–In Vitro Fertilization, Department of Obstetrics and Gynecology, Carmel Medical Center, Faculty of Medicine, Technion, Haifa, Israel; b St. Georges Hospital, London, United Kingdom; c London Bridge Gynecology Fertility and Genetic Centre, London, United Kingdom; d Division of Fertility–In Vitro Fertilization, Sheba Medical Center, Faculty of Medicine, Tel Aviv, Israel; and e In Vitro Fertilization Center, Isida, Kiev, Ukraine
Objective: To evaluate the effect of local endometrial injury (LEI) on clinical outcomes in ovum donation recipients. Design: Retrospective cohort analysis of ovum donation cycles conducted from 2005 to 2012. Setting: Two private IVF centers. Patient(s): Total 737 ovum donation cycles. Intervention(s): LEI by endometrial ‘‘scratch’’ with the use of a Pipelle catheter. Main Outcome Measure(s): Clinical pregnancy and live birth rates. Result(s): No statistically significant differences were found in clinical pregnancy rates and live birth rates in cycles subjected to LEI compared with those without. Combination of LEI with fibroid uterus resulted with significantly higher clinical pregnancy rates compared with LEI in normal uterine anatomy. Conclusion(s): This is the first study done in ovum recipients who underwent LEI by a ‘‘scratch’’ procedure after failed implantation. Unlike most previous reports, which found improved pregnancy rates with the use of ‘‘scratch effect’’ or ‘‘minor endometrial injury’’ after repeated implantation failures in standard IVF with own eggs, we did not find any changes in implantation rates in a population of egg recipients following this procedure. In view of a possible positive effect of LEI in cycles with a previous four or more failures, prospective randomized controlled studies are warranted to better define the target population who may benefit from this intervention. (Fertil SterilÒ 2014;102:1048–54. Ó2014 by American Society Use your smartphone for Reproductive Medicine.) to scan this QR code Key Words: Repeated implantation failure, local endometrial injury, endometrial scratch, ovum and connect to the donation, uterine factors Discuss: You can discuss this article with its authors and other ASRM members at http:// fertstertforum.com/dainl-endometrial-injury-pregnancy-ovum-donation/
I
mplantation is a multistep process, in which the embryo attaches to the endometrium and invades the deeper layers. A successful implantation is a vital event in the survival of an early pregnancy, and it depends mainly on two basic factors: embryo quality and endometrial receptivity (1). Despite enormous research in reproductive medicine and significant
advances in treatment protocols and techniques, repeated implantation failure (RIF) remains a major rate-limiting step in the process of assisted reproduction treatment (ART). RIF is defined as failure to achieve pregnancy after two to six IVF cycles over which more than ten good-quality embryos were transferred (2). In common practice, however, RIF is suspected after three
Received May 9, 2014; revised June 19, 2014; accepted June 27, 2014; published online July 23, 2014. L.D. has nothing to disclose. K.O. has nothing to disclose. D.B. has nothing to disclose. J.L. has nothing to disclose. V.Z. has nothing to disclose. S.W. has nothing to disclose. M.D. has nothing to disclose. Reprint requests: Martha Dirnfeld, M.D., Division of Fertility–In Vitro Fertilization, Department of Obstetrics and Gynecology, Carmel Medical Center, 7 Michal St., Haifa, Israel (E-mail: [email protected]). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.06.044 1048
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or more unsuccessful IVF cycles in which good-quality embryos were transferred (3). Most studies exploring interventions to improve the implantation rates have proposed various management options to influence embryonic factors, such as optimization of culture media, assisted hatching, modifying embryo transfer (ET) techniques, blastocyst transfer, and preimplantation genetic screening. In contrast, surprisingly fewer approaches have been suggested to overcome suboptimal endometrial receptivity, although that factor is estimated to cause up to two-thirds of implantation failures (4). Interventions include hormonal treatment, especially in cases VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® of thin endometrium, correction of intrauterine anatomic abnormalities, immunotherapy, and mechanical endometrial stimulation by local injury (3). The first observation that endometrial injury caused by scratching the progestational guinea pig uterus results in rapid growth of decidualized endometrial cells was reported by Leob in 1907 (5). Later trials in rats demonstrated that uterine injury by oil injection also provokes decidualization (6). These observations led to an assumption that endometrial injury could contribute to a successful implantation and to improved reproductive outcomes in unexplained RIF cases. One of the first studies that noted increased rates of implantation, clinical pregnancies, and live births following endometrial injury in women with RIF was published by Barash et al. in 2003 (7). Since then, several randomized (8, 9) and nonrandomized (10–12) controlled studies have demonstrated that local endometrial injury (LEI) significantly increases clinical pregnancy and implantation rates in IVF cycles. A meta-analysis by Potgar et al. in 2012, pooling seven controlled studies (four randomized and three nonrandomized) with a total of 2,062 participants, showed that LEI induced in the cycle preceding ovarian stimulation is 70% more likely to result in a clinical pregnancy compared with no intervention (13). A recent Cochrane analysis also reported that endometrial injury performed before the ET cycle improves clinical pregnancy and live birth rates in women undergoing ART, except for endometrial injury on the day of oocyte retrieval, which was found to be associated with significantly reduced ART outcome (14). The scientific explanation of the underlying mechanisms of endometrial injury is not fully understood. It was proposed that endometrial injury affects the expression of endometrial genes involved in the preparation of the endometrium for embryo implantation expression (15, 16) and induces local inflammatory reaction with increased production of cytokines and growth factors, which in turn promote decidual proliferation (17) or improve the synchronicity in interaction between the endometrium and the embryos (18). There are numerous confounding variables that complicate the analysis in studies comparing different groups of patients undergoing autologous IVF cycles. One of the major confounders is the woman's age, which can adversely affect embryo quality as well as endometrial functioning. Ovarian hyperstimulation is another variable that can not be controlled for and has possible adverse influence on embryo development and endometrial receptivity (19–21). Ovum donation cycles provide a unique model for partial elimination of the confounding factors related to autologous IVF treatment. Endometrial preparation in egg recipients is performed by a standard protocol of exogenous hormonal treatment and is less dependent on endogenous ovarian function. In addition, oocyte donors are typically young women with good ovarian reserve, thus embryo quality is expected to be relatively similar in terms of implantation potential. Therefore, the decreased variability of age, ovarian function, and embryo quality in oocyte donation cycles allows for a better exploration of the independent effect of interventions on endometrial receptivity. VOL. 102 NO. 4 / OCTOBER 2014
To the best of our knowledge, no studies have been published in the professional literature regarding the effects of LEI and pregnancy outcomes in ovum recipients. Therefore, the objective of the present study was to examine the influence of LEI by endometrial scratch with the use of a Pipelle catheter in the cycle before ET on clinical pregnancy and live birth rates a in a large cohort of ovum recipients.
MATERIALS AND METHODS The cohort study data were collected retrospectively from a computerized database. All oocyte donation cycles performed from June 2005 to October 2012 at two private IVF centers were reviewed. The local Institutional Review Board approved the study. Given the retrospective nature of the analyses, written informed consent was not required.
Oocyte Donors Oocyte donors were aged 23–30 years and had proven fertility. All underwent preliminary counseling and filled in a health questionnaire. Screening tests for human immunodeficiency virus, cytomegalovirus, syphilis and hepatitis, and genetic tests for Fragile X and CF were performed. Informed consent was undertaken prior to starting a treatment cycle. The protocol for ovarian stimulation, ovum retrieval, IVFICSI, and embryo handing in the laboratory was performed as previously described (22). ET was performed on day 2–6 post egg collection.
Recipients All recipients underwent general health assessments, implications counseling, and genetic counseling. Welfare of the child forms from their general practitioners were mandatory according to the Human Fertilization and Embryology Authority (HFEA) code of practice. All recipients underwent routine screening tests and assessment of uterine cavity by three-dimensional transvaginal ultrasound, saline solution sonohysterography, and/or diagnostic hysteroscopy. When present, endometrial polyps, intrauterine adhesions, and submucous myomas were removed with the use of operative hysteroscopy. Myomectomy was also performed in cases of myomas distorting the endometrial cavity according to sonographic findings, aquascan examination, or hysteroscopy. The protocol for recipients' hormonal treatment was maintained as previously described (23). Briefly, recipients received estradiol valerate (EV), initiated with a standard dose of 6 mg daily and increased according to the response. Menstruating women were synchronized with the use of low-dose oral contraceptive pill or GnRH agonist and started EV on day 5 after stopping oral contraception pill or on the desired day after down-regulation. Endometrial thickness was assessed by serial vaginal scans during the treatment cycle by measuring the maximal distance between the echogenic interfaces of the myometrium and endometrium in the plane through the central longitudinal axis of the uterine body. Endometrial pattern was defined as the type of relative echogenicity of the endometrium 1049
ORIGINAL ARTICLE: ASSISTED REPRODUCTION compared with adjacent myometrium (24). A multilayered endometrium, appearing as a triple-line pattern, was defined as grade A. A nonmultilayered homogeneous endometrium was defined as grade C. An intermediate endometrium, with some elements of a well defined central echogenic line, was defined as grade B.
Technique of LEI LEI was offered according to the clinical judgment of the managing physician. It was performed once on day 20–22 of the spontaneous menstrual cycle or 1–2 weeks preceding the ovum donation cycle before starting EV. Endometrial scratch was performed with the use of a biopsy catheter (Pipelle de Cornier; Laboratories Prodimed). After introducing the Pipelle catheter into the uterine cavity and withdrawing the piston, the catheter was moved back-and-forth over the whole uterine cavity.
Progesterone Support, ET, and Follow-up On the day of recovery of ovum donation, recipients started intravaginal progesterone: 800 mg/d Uterogestan. Ultrasound-guided ET was performed 2–6 days after oocyte recovery. Ultrasound examinations were performed 2– 3 weeks after positive b-hCG test results. Clinical pregnancy was defined as visualization of a gestational sac with a positive fetal heartbeat. Biochemical pregnancy was determined by an initial rise and subsequent decrease in serum b-hCG concentrations without any sonographic findings. A miscarriage was defined as a pregnancy loss before gestational week 12, after sonographic visualization of an intrauterine gestational sac at 5–6 weeks of gestation. Live birth was defined as a pregnancy that ended with delivery of live infant(s).
Statistical Analysis Data were analyzed with the use of SPSS software. P< .05 was considered to be statistically significant. Continuous variables are presented as mean SD and were tested by Student t test. Categoric data are expressed as numbers and were compared with the use of the chi-square test. Logistic regression was performed to determine the independent effect of individual variables on clinical outcome.
In 129 cycles (17.5%), recipients received increased dosages of estrogen treatment. The mean day of ET was 2.67 0.58 days, and the mean number of transferred embryos per cycle was 2.55 0.65. The number of fresh ET cycles was 624 (84.7% of the procedures), and the remaining involved frozen embryo transfer (FET; 47 cycles, 6.4%) or combined fresh ET and FET (66 cycles, 8.9%). The 737 oocyte retrieval–ET cycles resulted in 278 pregnancies (37.7%). Of them, 57 ended in biochemical pregnancies (20.5% of pregnancies), 3 were ectopic (1.1%), 44 resulted in spontaneous miscarriages (15.8%), 4 (1.4%) terminated in stillbirth, and 170 resulted in live births (61.2%). Fresh ETs achieved significantly more pregnancies than did FETs (32.4% vs. 10.6%), and combined ETs resulted in clinical pregnancy in 21.2% of the cycles. No statistically significant differences were observed between recipients who achieved a clinical pregnancy and those who did not conceive regarding mean values of female and male partners' ages, number of embryos transferred, distributions of hysteroscopy findings and endometrial grade, or most importantly, the number of Pipelle scratch (39 [17.6%] vs. 83 [16.1%]; P¼ .601) or hysteroscopic (82 [37.1%] vs. 221 [42.8%]; P¼ .148) procedures. The clinical pregnancy group rate was significantly lower in patients receiving additional estrogen treatment (29 [13.1%] vs. 100 [19.4%]; P¼ .041), and higher with fresh ETs (202 [91.4%] vs. 422 [81.8]; P¼ .001). Table 1 compares pregnancy outcomes in the cycles with and without Pipelle scratch. The groups did not differ in overall pregnancy rates, clinical pregnancy rates, or live birth rates. Of note, pregnancies were achieved after up to 11 treatment failures. Because some of the outcomes had very small numbers, outcomes were combined by grouping ‘‘no pregnancy’’ with ‘‘biochemical pregnancies’’ (first combined group), and ‘‘early miscarriage,’’ ‘‘ectopic pregnancies,’’ and ‘‘stillborn’’ cases to create a group of unwanted clinical pregnancy outcomes. According to this grouped analysis, still no differences in live birth rates were found. The 122 recipient women who underwent Pipelle scratch were older (45.2 4.7 y vs. 43.9 4.5 y; P¼ .002) than the group that was not treated with Pipelle scratch, and they received significantly more treatment cycles (4.14 2.0 vs. 1.99 1.35; P< .0001), more embryos in each cycle (2.9 0.7 vs. 2.5 0.6; P< .0001), and more additional estrogen
RESULTS A total of 737 donor oocyte transfers were analyzed. Recipient age ranged from 25 to 56 years. Indications for oocyte donation were failure to conceive after more than four IVF cycles (224 cycles, 30.5%), premature ovarian failure (48 cycles, 6.5%), natural menopause (63 cycles, 8.6%), advanced maternal age (>44 y; 365 cycles, 49.5%), and repeated miscarriage (37 cycles, 5%). Diagnostic procedures failed to reveal a significant pathology in 436 cycles (59.2%), although fibroid uterus was diagnosed in 254 cycles (34.5%), endometrial polyps in 30 cycles (4%), and intrauterine adhesions in 16 cycles (2.2%). Of 672 cycles in which endometrial grade was noted, 172 (25.6% of the assessments) had grade A scores, 454 (67.6%) grade B, and 46 (6.8%) grade C. 1050
TABLE 1 Pregnancy outcomes in the cycles with and without Pipelle scratch. Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 615)
Outcome
n
%
n
%
No pregnancy Clinical pregnancy Biochemical pregnancy Early miscarriage Ectopic pregnancy Late abortion Live birth
76 39 7 9 1 0 29
62.3 32 5.7 7.4 0.8 0 23.8
383 182 50 35 2 4 141
62.3 29.6 8.1 5.7 0.3 0.7 22.9
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Fertility and Sterility® treatment (27% vs. 15.6%; P¼ .002). Their endometrium was thinner (8.02 1.9 vs. 8.65 1.9 mm; P¼ .001), with lower proportion of grade A (14 13.1 vs. 158 28.0; P¼ .001) and higher proportion of grade B (85 79.4 vs. 369 65.3; P¼ .004) cases. In addition, this group underwent significantly more hysteroscopy procedures (65.6% vs. 36.3%; P< .0001). No difference was found between cycles with and without Pipelle scratch in male age, type of embryos transferred, or hysteroscopy findings. Table 2 presents clinical pregnancy rates according to hysteroscopy findings. With the use of a chi-square analysis, significantly more clinical pregnancies were noted after Pipelle scratch procedure in women with fibroid uteri (P¼ .012). Because only 30 cases of endometrial polyps and 16 cases of endometrial adhesions were found, these cycles were omitted from the calculation. In the 114 remaining cases that underwent Pipelle, more pregnancies were still noted in cycles with fibroid uterus than in cases in which no uterine anatomic abnormalities were noted (52.9% vs. 25%; P¼ .004). No significant differences were shown in clinical pregnancy rates according to cycle number in cycles with (P¼ .614) and without (P¼ .481) Pipelle scratch (Table 3). A separate calculation was performed to evaluate the effect of Pipelle scratch on oocyte donation cycle outcomes according to the cutoff of three, four, or five previously failed cycles. No significant differences were shown in this analysis (P values of .488, .07, and .648, respectively). According to receiver operating characteristic curve (not shown), no marker point was found in the Pipelle scratch group above which there were significantly more clinical pregnancies. In addition, we examined the effect of performing Pipelle scratch and hysteroscopy in the same cycle and compared it to the outcomes of only one of these interventions (Table 4). That analysis did not show any significant differences in oocyte donation outcomes.
findings showed no statistically significant differences in clinical pregnancy rates (32% vs. 29.6%) and live birth rates (23.8% vs. 22.9%) in, respectively, women that underwent Pipelle scratch versus those who did not. The significant advantage of the present study is the analysis in ovum donation cycles and neutralization of most embryonic factors, which could influence IVF treatments. Still, one of the major obstacles of any retrospective study is the limitation in controlling confounding factors which may influence outcomes. For example, in the present study women who had an LEI Pipelle procedure were found to be older than those who did not undergo the procedure. This parameter by itself could adversely influence pregnancy rates in this group, because a significant relationship between increasing recipient age and declining implantation was reported by several studies (25–27). This impairment of uterine receptivity with increased maternal age has been related to diminished uterine blood flow (28, 29), reduced progesterone sensitivity (30), and various histologic alterations, such as stromal angiosclerosis and extracellular matrix deposition (26, 28). However, other recent studies did not find an effect of recipient age on success rates (31). An additional disadvantage of cycles chosen for Pipelle scratch was a lower proportion of grade A endometrium in the LEI group. According to several studies, endometrial grade can significantly affect implantation and clinical pregnancy rates (32, 33). Also, the endometrium of recipients chosen for Pipelle scratch was thinner, although within normal accepted ranges (8.02 mm vs. 8.65 mm, respectively). In a previous study (34), we showed that more live births were observed in oocyte donation cycles for an endometrial thickness cutoff of 8.2 mm than for thinner endometrium or endometrium thicker than 9.6 mm, a finding supported by additional studies (19, 35). Finally, cycles in which Pipelle scratch was performed exhibited significantly higher numbers of prior oocyte donation failures. This implies a higher proportion of RIF cases in cycles chosen for Pipelle scratch, but this is the population of patients that have been offered LEI by all previous studies. A second group of confounding factors demonstrated in our study is the dissimilar management given to women in the Pipelle scratch group, which entailed higher doses of estrogens and more hysteroscopic procedures. However, this finding reflects the unfavorable prognostic characteristics in women chosen to undergo Pipelle scratch, as described above (older age, more failed cycles, and worse endometrial
DISCUSSION Our findings show that endometrial injury with the use of Pipelle scratch did not improve pregnancy and live birth rates in ovum recipients with RIF. To our knowledge, this is one of the first large-cohort published studies determined to examine the influence of LEI in oocyte donation recipients. LEI by Pipelle procedure was performed in 16.5% of the cycles. Of those 122 cycles, 46 pregnancies were achieved, including 39 clinical pregnancies and 29 live births. Our
TABLE 2 Clinical pregnancy rates [CPRs, n (%)] according to hysteroscopy findings with and without Pipelle scratch. Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 614)
Uterine factor
Total
All patients (n [ 736) CPR
Total
CPR
Total
CPR
None Fibroid uterus Endometrial polyp Intrauterine adhesions P value
436 254 30 16
136 (31.2) 76 (29.9) 8 (26.7) 1 (6.2)
80 34 3 5
20 (25.0) 18 (52.9) 0 1 (20.0)
356 220 27 11
116 (32.6) 58 (26.4) 8 (29.6) 0
.190
.012
.061
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION
TABLE 3 Clinical pregnancy rates [CPRs, n (%)] according to IVF cycle number with and without Pipelle scratch. All patients (n [ 737)
Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 615)
Cycle number
Total
CPR
Total
CPR
Total
CPR
1 2 3 4 5 6 7 8 9 10 11 >3 cycles >4 cycles >5 cycles
293 205 103 57 35 20 10 7 4 2 1 136 79 44
90 (30.7) 60 (29.3) 37 (35.9) 15 (26.3) 8 (22.9) 4 (20.0) 1 (10.0) 3 (42.9) 1 (25.0) 1 (50.0) 1 (100) 34 (25) 19 (24.1) 11 (25)
7 17 29 25 18 11 6 5 2 1 1 69 44 26
2 (28.6) 7 (41.2) 11 (37.9) 5 (20.0) 6 (33.3) 2 (18.2) 1 (16.7) 3 (60) 1 (50.0) 0 1 (100) 19 (27.5) 14 (31.8) 8 (30.8)
286 188 74 32 17 9 4 2 2 1 0 67 35 18
88 (30.8) 53 (28.2) 26 (35.1) 10 (31.2) 2 (11.8) 2 (22.2) 0 0 0 1 (100) 15 (22.4) 5 (14.3) 3 (16.7)
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condition). For example, women in the Pipelle scratch group received significantly more embryos in each cycle, even though in donor egg cycles, according to accepted guidelines, the age of the donor should be used to determine the appropriate number of embryos to transfer (36). In addition, women chosen for Pipelle scratch procedure also received more estrogen treatment, despite insufficient evidence in favor of that action (34, 37). Regarding anatomic factors, surprisingly fibroid uterus has been found to be a positive prognostic factor for the achievement of clinical pregnancy in the group that underwent Pipelle scratch. We note that myomectomy was performed at the time of hysteroscopy in those patients who were diagnosed with a submucous fibroid. If this is the case, the myomectomy was the major endometrial insult and not the Pipelle scratch. It would be incorrect to conclude that patients with fibroids do better with endometrial injury when a more significant intervention (myomectomy) was performed. Another point worth discussing is patient selection for the LEI. Prospective studies examining the influence of this procedure on the success of IVF treatment have used different inclusion criteria regarding minimum number of prior IVF attempts, varying from one to four (8–12). This is not surprising, because there are no formal criteria regarding the number of failed cycles for definition of RIF. According
to a United Kingdom survey performed in 65 licensed infertility centers, the definition of recurrent failure ranged from two to six prior treatment cycles, with three fresh IVF attempts being most frequently reported (2). In the present trial we tried to define the optimal number of failed cycles above which the Pipelle procedure would show its best effect. However, no significant benefit of Pipelle scratch was found in women with three, four, or five previously failed cycles. It is worth mentioning that in 79 women with four oocyte donation failures, the Pipelle scratch group showed clinical pregnancy rate of 31.8%, compared with 14.3% in cycles without Pipelle scratch. This difference did not reach statistical significance (P¼ .07), probably because of a relatively small number of cycles in each group. This may imply that the criterion for patient selection to undergo LEI could possibly be set to at least four previously failed implantation following ovum donation cycles, but clearly larger prospective studies are required to further evaluate this issue. Of note, as can be seen in our study, pregnancies can be achieved after multiple cycle failures (up to 11). Although many ART centers discontinue treatment after 3–4 failures, our findings confirm earlier reports that chances of achieving a live birth can be viable after several ETs (85.1% within eight treatment cycles) (38).
TABLE 4 Outcomes of oocyte donation cycles according to the interventions performed. Clinical pregnancy (n [ 221) Type of treatment None (n ¼ 392) Pipelle scratch only (n ¼ 42) Hysteroscopy only (n ¼ 223) Hysteroscopy and Pipelle scratch (n ¼ 80) P value
No clinical pregnancy (n [ 516)
Live delivery (n [ 170)
No live delivery (n [ 567)
n
%
n
%
n
%
n
%
126 13 56 26
32.1 31 25.1 26
266 29 167 54
67.9 69 74.9 67.5
98 10 43 19
25 23.8 19.3 23.8
294 32 180 61
75 76.2 80.7 76.2
.215
.324
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Fertility and Sterility® Another still unanswered question regarding LEI is the number of such procedures needed for an optimal outcome. A systematic review by El-Toukhy et al. described two randomized (n ¼ 193) and six nonrandomized (n ¼ 708) controlled studies comparing the outcome of IVF treatment in patients who had LEI in the cycle preceding their IVF treatment with control subjects in which endometrial injury was not performed (39). That investigation showed meaningful variability in the frequency of the intervention among the eight studies, with LEI performed only once before the IVF cycle in five studies, twice in 2-studies (9, 11), and on four occasions in one study (7). In the present study, we found no differences in the reproductive outcomes between cycles in which only Pipelle scratch was performed, those combining Pipelle scratch with hysteroscopy, and those with hysteroscopy alone. Because no randomized controlled studies have been published regarding the optimal number of LEI procedures performed in a single cycle, this question also remains unanswered. In conclusion, our findings have not demonstrated a positive effect of LEI on achieving pregnancy in ovum donation cycles, but a tendency toward improvement was observed when LEI was performed after four implantation failures. Although the sample size, 737 ovum donation cycles, is large, the retrospective nature of this analysis limits drawing solid definitive conclusions on the value of LEI. No beneficial effect was shown in combining Pipelle scratch with hysteroscopy procedure. This last point, as well as defining the optimal number of previously failed oocyte donation cycles for deciding on LEI, should be evaluated in large-cohort randomized prospective clinical trials.
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Guven S, Kart C, Unsal MA, Yildirim O, Odaci E, Yulug E. Endometrial injury may increase the clinical pregnancy rate in normoresponders undergoing long agonist protocol ICSI cycles with single embryo transfer. Eur J Obstet Gynecol Reprod Biol 2014;173:58–62. Raziel A, Schachter M, Strassburger D, Bern O, Ron-El R, Friedler S. Favorable influence of local injury to the endometrium in intracytoplasmic sperm injection patients with high-order implantation failure. Fertil Steril 2007;87:198–201. Zhou L, Li R, Wang R, Huang HX, Zhong K. Local injury to the endometrium in controlled ovarian hyperstimulation cycles improves implantation rates. Fertil Steril 2008;89:1166–76. Potdar N, Gelbaya T, Nardo LG. Endometrial injury to overcome recurrent embryo implantation failure: a systematic review and meta-analysis. Reprod Biomed Online 2012;25:561–71. Karimzade MA, Oskouian H, Ahmadi S, Oskouian L. Local injury to the endometrium on the day of oocyte retrieval has a negative impact on implantation in assisted reproductive cycles: a randomized controlled trial. Arch Gynecol Obstet 2010;281:499–503. Dekel N, Gnainsky Y, Granot I, Mor G. Inflammation and implantation. Am J Reprod Immunol 2010;63:17–21. Kalma Y, Granot I, Gnainsky Y, Or Y, Czernobilsky B, Dekel N, et al. Endometrial biopsy-induced gene modulation: first evidence for the expression of bladder-transmembranal uroplakin Ib in human endometrium. Fertil Steril 2009;91:1042–9. 1049 e1–9. Gnainsky Y, Granot I, Aldo PB, Barash A, Or Y, Schechtman E, et al. Local injury of the endometrium induces an inflammatory response that promotes successful implantation. Fertil Steril 2010;94:2030–6. Li R, Hao G. Local injury to the endometrium: its effect on implantation. Curr Opin Obstet Gynecol 2009;21:236–9. Zenke U, Chetkowski RJ. Transfer and uterine factors are the major recipientrelated determinants of success with donor eggs. Fertil Steril 2004;82:850–6. Noyes N, Hampton BS, Berkeley A, Licciardi F, Grifo J, Krey L. Factors useful in predicting the success of oocyte donation: a 3-year retrospective analysis. Fertil Steril 2001;76:92–7. n C. Factors Garcia-Velasco JA, Isaza V, Caligara C, Pellicer A, Remohí J, Simo that determine discordant outcome from shared oocytes. Fertil Steril 2003; 80:54–60. n C, Miro F, Castellví RM, Ruiz A, Ruiz M, et al. Ovarian Pellicer A, Simo response and outcome of in-vitro fertilization in patients treated with gonadotrophin-releasing hormone analogues in different phases of the menstrual cycle. Hum Reprod 1989;4:285–9. n C, Pellicer A. Long oestradiol Remohí J, Gutierrez A, Cano F, Ruiz A, Simo replacement in an oocyte donation programme. Hum Reprod 1995;10: 1387–91. Barker MA, Boehnlein LM, Kovacs P, Lindheim SR. Follicular and luteal phase endometrial thickness and echogenic pattern and pregnancy outcome in oocyte donation cycles. J Assist Reprod Genet 2009;26:243–9. Gupta P, Banker M, Patel P, Joshi B. A study of recipient related predictors of success in oocyte donation program. J Hum Reprod Sci 2012;5:252–7. Toner JP, Grainger DA, Frazier LM. Clinical outcomes among recipients of donated eggs: an analysis of the U.S. national experience, 1996–1998. Fertil Steril 2002;78:1038–45. Moomjy M, Cholst I, Mangieri R, Rosenwaks Z. Oocyte donation: insights into implantation. Fertil Steril 1999;71:15–21. Soares SR, Velasco JA, Fernandez M, Bosch E, Remohí J, Pellicer A, et al. Clinical factors affecting endometrial receptiveness in oocyte donation cycles. Fertil Steril 2008;89:491–501. Meldrum DR. Female reproductive aging–ovarian and uterine factors. Fertil Steril 1993;59:1–5. Steer CV, Tan SL, Mason BA, Campbell S. Midluteal-phase vaginal color Doppler assessment of uterine artery impedance in a subfertile population. Fertil Steril 1994;61:53–8. Martínez F, Latre L, Clua E, Rodriguez I, Coroleu B. Replacing GnRH agonists with GnRH antagonists in oocyte recipient cycle did not adversely affect the pregnancy rates. Eur J Obstet Gynecol Reprod Biol 2011;159:355–8. Zhao J, Zhang Q, Li Y. The effect of endometrial thickness and pattern measured by ultrasonography on pregnancy outcomes during IVF-ET cycles. Reprod Biol Endocrinol 2012;10:100.
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Criteria for number of embryos to transfer: a committee opinion. Fertil Steril 2013;99:44–6. n C, Pellicer A. EndoRemohí J, Ardiles G, García-Velasco JA, Gaitan P, Simo metrial thickness and serum oestradiol concentrations as predictors of outcome in oocyte donation. Hum Reprod 1997;12:2271–6. Lande Y, Seidman DS, Maman E, Baum M, Dor J, Hourvitz A. Couples offered free assisted reproduction treatment have a very high chance of achieving a live birth within 4 years. Fertil Steril 2011;95:568–72. El-Toukhy T, Sunkara S, Khalaf Y. Local endometrial injury and IVF outcome: a systematic review and meta-analysis. Reprod Biomed Online 2012;25:345–54.
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Division of Fertility–In Vitro Fertilization, Department of Obstetrics and Gynecology, Carmel Medical Center, Faculty of Medicine, Technion, Haifa, Israel; b St. Georges Hospital, London, United Kingdom; c London Bridge Gynecology Fertility and Genetic Centre, London, United Kingdom; d Division of Fertility–In Vitro Fertilization, Sheba Medical Center, Faculty of Medicine, Tel Aviv, Israel; and e In Vitro Fertilization Center, Isida, Kiev, Ukraine
Objective: To evaluate the effect of local endometrial injury (LEI) on clinical outcomes in ovum donation recipients. Design: Retrospective cohort analysis of ovum donation cycles conducted from 2005 to 2012. Setting: Two private IVF centers. Patient(s): Total 737 ovum donation cycles. Intervention(s): LEI by endometrial ‘‘scratch’’ with the use of a Pipelle catheter. Main Outcome Measure(s): Clinical pregnancy and live birth rates. Result(s): No statistically significant differences were found in clinical pregnancy rates and live birth rates in cycles subjected to LEI compared with those without. Combination of LEI with fibroid uterus resulted with significantly higher clinical pregnancy rates compared with LEI in normal uterine anatomy. Conclusion(s): This is the first study done in ovum recipients who underwent LEI by a ‘‘scratch’’ procedure after failed implantation. Unlike most previous reports, which found improved pregnancy rates with the use of ‘‘scratch effect’’ or ‘‘minor endometrial injury’’ after repeated implantation failures in standard IVF with own eggs, we did not find any changes in implantation rates in a population of egg recipients following this procedure. In view of a possible positive effect of LEI in cycles with a previous four or more failures, prospective randomized controlled studies are warranted to better define the target population who may benefit from this intervention. (Fertil SterilÒ 2014;102:1048–54. Ó2014 by American Society Use your smartphone for Reproductive Medicine.) to scan this QR code Key Words: Repeated implantation failure, local endometrial injury, endometrial scratch, ovum and connect to the donation, uterine factors Discuss: You can discuss this article with its authors and other ASRM members at http:// fertstertforum.com/dainl-endometrial-injury-pregnancy-ovum-donation/
I
mplantation is a multistep process, in which the embryo attaches to the endometrium and invades the deeper layers. A successful implantation is a vital event in the survival of an early pregnancy, and it depends mainly on two basic factors: embryo quality and endometrial receptivity (1). Despite enormous research in reproductive medicine and significant
advances in treatment protocols and techniques, repeated implantation failure (RIF) remains a major rate-limiting step in the process of assisted reproduction treatment (ART). RIF is defined as failure to achieve pregnancy after two to six IVF cycles over which more than ten good-quality embryos were transferred (2). In common practice, however, RIF is suspected after three
Received May 9, 2014; revised June 19, 2014; accepted June 27, 2014; published online July 23, 2014. L.D. has nothing to disclose. K.O. has nothing to disclose. D.B. has nothing to disclose. J.L. has nothing to disclose. V.Z. has nothing to disclose. S.W. has nothing to disclose. M.D. has nothing to disclose. Reprint requests: Martha Dirnfeld, M.D., Division of Fertility–In Vitro Fertilization, Department of Obstetrics and Gynecology, Carmel Medical Center, 7 Michal St., Haifa, Israel (E-mail: [email protected]). Fertility and Sterility® Vol. 102, No. 4, October 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2014.06.044 1048
discussion forum for this article now.*
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or more unsuccessful IVF cycles in which good-quality embryos were transferred (3). Most studies exploring interventions to improve the implantation rates have proposed various management options to influence embryonic factors, such as optimization of culture media, assisted hatching, modifying embryo transfer (ET) techniques, blastocyst transfer, and preimplantation genetic screening. In contrast, surprisingly fewer approaches have been suggested to overcome suboptimal endometrial receptivity, although that factor is estimated to cause up to two-thirds of implantation failures (4). Interventions include hormonal treatment, especially in cases VOL. 102 NO. 4 / OCTOBER 2014
Fertility and Sterility® of thin endometrium, correction of intrauterine anatomic abnormalities, immunotherapy, and mechanical endometrial stimulation by local injury (3). The first observation that endometrial injury caused by scratching the progestational guinea pig uterus results in rapid growth of decidualized endometrial cells was reported by Leob in 1907 (5). Later trials in rats demonstrated that uterine injury by oil injection also provokes decidualization (6). These observations led to an assumption that endometrial injury could contribute to a successful implantation and to improved reproductive outcomes in unexplained RIF cases. One of the first studies that noted increased rates of implantation, clinical pregnancies, and live births following endometrial injury in women with RIF was published by Barash et al. in 2003 (7). Since then, several randomized (8, 9) and nonrandomized (10–12) controlled studies have demonstrated that local endometrial injury (LEI) significantly increases clinical pregnancy and implantation rates in IVF cycles. A meta-analysis by Potgar et al. in 2012, pooling seven controlled studies (four randomized and three nonrandomized) with a total of 2,062 participants, showed that LEI induced in the cycle preceding ovarian stimulation is 70% more likely to result in a clinical pregnancy compared with no intervention (13). A recent Cochrane analysis also reported that endometrial injury performed before the ET cycle improves clinical pregnancy and live birth rates in women undergoing ART, except for endometrial injury on the day of oocyte retrieval, which was found to be associated with significantly reduced ART outcome (14). The scientific explanation of the underlying mechanisms of endometrial injury is not fully understood. It was proposed that endometrial injury affects the expression of endometrial genes involved in the preparation of the endometrium for embryo implantation expression (15, 16) and induces local inflammatory reaction with increased production of cytokines and growth factors, which in turn promote decidual proliferation (17) or improve the synchronicity in interaction between the endometrium and the embryos (18). There are numerous confounding variables that complicate the analysis in studies comparing different groups of patients undergoing autologous IVF cycles. One of the major confounders is the woman's age, which can adversely affect embryo quality as well as endometrial functioning. Ovarian hyperstimulation is another variable that can not be controlled for and has possible adverse influence on embryo development and endometrial receptivity (19–21). Ovum donation cycles provide a unique model for partial elimination of the confounding factors related to autologous IVF treatment. Endometrial preparation in egg recipients is performed by a standard protocol of exogenous hormonal treatment and is less dependent on endogenous ovarian function. In addition, oocyte donors are typically young women with good ovarian reserve, thus embryo quality is expected to be relatively similar in terms of implantation potential. Therefore, the decreased variability of age, ovarian function, and embryo quality in oocyte donation cycles allows for a better exploration of the independent effect of interventions on endometrial receptivity. VOL. 102 NO. 4 / OCTOBER 2014
To the best of our knowledge, no studies have been published in the professional literature regarding the effects of LEI and pregnancy outcomes in ovum recipients. Therefore, the objective of the present study was to examine the influence of LEI by endometrial scratch with the use of a Pipelle catheter in the cycle before ET on clinical pregnancy and live birth rates a in a large cohort of ovum recipients.
MATERIALS AND METHODS The cohort study data were collected retrospectively from a computerized database. All oocyte donation cycles performed from June 2005 to October 2012 at two private IVF centers were reviewed. The local Institutional Review Board approved the study. Given the retrospective nature of the analyses, written informed consent was not required.
Oocyte Donors Oocyte donors were aged 23–30 years and had proven fertility. All underwent preliminary counseling and filled in a health questionnaire. Screening tests for human immunodeficiency virus, cytomegalovirus, syphilis and hepatitis, and genetic tests for Fragile X and CF were performed. Informed consent was undertaken prior to starting a treatment cycle. The protocol for ovarian stimulation, ovum retrieval, IVFICSI, and embryo handing in the laboratory was performed as previously described (22). ET was performed on day 2–6 post egg collection.
Recipients All recipients underwent general health assessments, implications counseling, and genetic counseling. Welfare of the child forms from their general practitioners were mandatory according to the Human Fertilization and Embryology Authority (HFEA) code of practice. All recipients underwent routine screening tests and assessment of uterine cavity by three-dimensional transvaginal ultrasound, saline solution sonohysterography, and/or diagnostic hysteroscopy. When present, endometrial polyps, intrauterine adhesions, and submucous myomas were removed with the use of operative hysteroscopy. Myomectomy was also performed in cases of myomas distorting the endometrial cavity according to sonographic findings, aquascan examination, or hysteroscopy. The protocol for recipients' hormonal treatment was maintained as previously described (23). Briefly, recipients received estradiol valerate (EV), initiated with a standard dose of 6 mg daily and increased according to the response. Menstruating women were synchronized with the use of low-dose oral contraceptive pill or GnRH agonist and started EV on day 5 after stopping oral contraception pill or on the desired day after down-regulation. Endometrial thickness was assessed by serial vaginal scans during the treatment cycle by measuring the maximal distance between the echogenic interfaces of the myometrium and endometrium in the plane through the central longitudinal axis of the uterine body. Endometrial pattern was defined as the type of relative echogenicity of the endometrium 1049
ORIGINAL ARTICLE: ASSISTED REPRODUCTION compared with adjacent myometrium (24). A multilayered endometrium, appearing as a triple-line pattern, was defined as grade A. A nonmultilayered homogeneous endometrium was defined as grade C. An intermediate endometrium, with some elements of a well defined central echogenic line, was defined as grade B.
Technique of LEI LEI was offered according to the clinical judgment of the managing physician. It was performed once on day 20–22 of the spontaneous menstrual cycle or 1–2 weeks preceding the ovum donation cycle before starting EV. Endometrial scratch was performed with the use of a biopsy catheter (Pipelle de Cornier; Laboratories Prodimed). After introducing the Pipelle catheter into the uterine cavity and withdrawing the piston, the catheter was moved back-and-forth over the whole uterine cavity.
Progesterone Support, ET, and Follow-up On the day of recovery of ovum donation, recipients started intravaginal progesterone: 800 mg/d Uterogestan. Ultrasound-guided ET was performed 2–6 days after oocyte recovery. Ultrasound examinations were performed 2– 3 weeks after positive b-hCG test results. Clinical pregnancy was defined as visualization of a gestational sac with a positive fetal heartbeat. Biochemical pregnancy was determined by an initial rise and subsequent decrease in serum b-hCG concentrations without any sonographic findings. A miscarriage was defined as a pregnancy loss before gestational week 12, after sonographic visualization of an intrauterine gestational sac at 5–6 weeks of gestation. Live birth was defined as a pregnancy that ended with delivery of live infant(s).
Statistical Analysis Data were analyzed with the use of SPSS software. P< .05 was considered to be statistically significant. Continuous variables are presented as mean SD and were tested by Student t test. Categoric data are expressed as numbers and were compared with the use of the chi-square test. Logistic regression was performed to determine the independent effect of individual variables on clinical outcome.
In 129 cycles (17.5%), recipients received increased dosages of estrogen treatment. The mean day of ET was 2.67 0.58 days, and the mean number of transferred embryos per cycle was 2.55 0.65. The number of fresh ET cycles was 624 (84.7% of the procedures), and the remaining involved frozen embryo transfer (FET; 47 cycles, 6.4%) or combined fresh ET and FET (66 cycles, 8.9%). The 737 oocyte retrieval–ET cycles resulted in 278 pregnancies (37.7%). Of them, 57 ended in biochemical pregnancies (20.5% of pregnancies), 3 were ectopic (1.1%), 44 resulted in spontaneous miscarriages (15.8%), 4 (1.4%) terminated in stillbirth, and 170 resulted in live births (61.2%). Fresh ETs achieved significantly more pregnancies than did FETs (32.4% vs. 10.6%), and combined ETs resulted in clinical pregnancy in 21.2% of the cycles. No statistically significant differences were observed between recipients who achieved a clinical pregnancy and those who did not conceive regarding mean values of female and male partners' ages, number of embryos transferred, distributions of hysteroscopy findings and endometrial grade, or most importantly, the number of Pipelle scratch (39 [17.6%] vs. 83 [16.1%]; P¼ .601) or hysteroscopic (82 [37.1%] vs. 221 [42.8%]; P¼ .148) procedures. The clinical pregnancy group rate was significantly lower in patients receiving additional estrogen treatment (29 [13.1%] vs. 100 [19.4%]; P¼ .041), and higher with fresh ETs (202 [91.4%] vs. 422 [81.8]; P¼ .001). Table 1 compares pregnancy outcomes in the cycles with and without Pipelle scratch. The groups did not differ in overall pregnancy rates, clinical pregnancy rates, or live birth rates. Of note, pregnancies were achieved after up to 11 treatment failures. Because some of the outcomes had very small numbers, outcomes were combined by grouping ‘‘no pregnancy’’ with ‘‘biochemical pregnancies’’ (first combined group), and ‘‘early miscarriage,’’ ‘‘ectopic pregnancies,’’ and ‘‘stillborn’’ cases to create a group of unwanted clinical pregnancy outcomes. According to this grouped analysis, still no differences in live birth rates were found. The 122 recipient women who underwent Pipelle scratch were older (45.2 4.7 y vs. 43.9 4.5 y; P¼ .002) than the group that was not treated with Pipelle scratch, and they received significantly more treatment cycles (4.14 2.0 vs. 1.99 1.35; P< .0001), more embryos in each cycle (2.9 0.7 vs. 2.5 0.6; P< .0001), and more additional estrogen
RESULTS A total of 737 donor oocyte transfers were analyzed. Recipient age ranged from 25 to 56 years. Indications for oocyte donation were failure to conceive after more than four IVF cycles (224 cycles, 30.5%), premature ovarian failure (48 cycles, 6.5%), natural menopause (63 cycles, 8.6%), advanced maternal age (>44 y; 365 cycles, 49.5%), and repeated miscarriage (37 cycles, 5%). Diagnostic procedures failed to reveal a significant pathology in 436 cycles (59.2%), although fibroid uterus was diagnosed in 254 cycles (34.5%), endometrial polyps in 30 cycles (4%), and intrauterine adhesions in 16 cycles (2.2%). Of 672 cycles in which endometrial grade was noted, 172 (25.6% of the assessments) had grade A scores, 454 (67.6%) grade B, and 46 (6.8%) grade C. 1050
TABLE 1 Pregnancy outcomes in the cycles with and without Pipelle scratch. Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 615)
Outcome
n
%
n
%
No pregnancy Clinical pregnancy Biochemical pregnancy Early miscarriage Ectopic pregnancy Late abortion Live birth
76 39 7 9 1 0 29
62.3 32 5.7 7.4 0.8 0 23.8
383 182 50 35 2 4 141
62.3 29.6 8.1 5.7 0.3 0.7 22.9
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Fertility and Sterility® treatment (27% vs. 15.6%; P¼ .002). Their endometrium was thinner (8.02 1.9 vs. 8.65 1.9 mm; P¼ .001), with lower proportion of grade A (14 13.1 vs. 158 28.0; P¼ .001) and higher proportion of grade B (85 79.4 vs. 369 65.3; P¼ .004) cases. In addition, this group underwent significantly more hysteroscopy procedures (65.6% vs. 36.3%; P< .0001). No difference was found between cycles with and without Pipelle scratch in male age, type of embryos transferred, or hysteroscopy findings. Table 2 presents clinical pregnancy rates according to hysteroscopy findings. With the use of a chi-square analysis, significantly more clinical pregnancies were noted after Pipelle scratch procedure in women with fibroid uteri (P¼ .012). Because only 30 cases of endometrial polyps and 16 cases of endometrial adhesions were found, these cycles were omitted from the calculation. In the 114 remaining cases that underwent Pipelle, more pregnancies were still noted in cycles with fibroid uterus than in cases in which no uterine anatomic abnormalities were noted (52.9% vs. 25%; P¼ .004). No significant differences were shown in clinical pregnancy rates according to cycle number in cycles with (P¼ .614) and without (P¼ .481) Pipelle scratch (Table 3). A separate calculation was performed to evaluate the effect of Pipelle scratch on oocyte donation cycle outcomes according to the cutoff of three, four, or five previously failed cycles. No significant differences were shown in this analysis (P values of .488, .07, and .648, respectively). According to receiver operating characteristic curve (not shown), no marker point was found in the Pipelle scratch group above which there were significantly more clinical pregnancies. In addition, we examined the effect of performing Pipelle scratch and hysteroscopy in the same cycle and compared it to the outcomes of only one of these interventions (Table 4). That analysis did not show any significant differences in oocyte donation outcomes.
findings showed no statistically significant differences in clinical pregnancy rates (32% vs. 29.6%) and live birth rates (23.8% vs. 22.9%) in, respectively, women that underwent Pipelle scratch versus those who did not. The significant advantage of the present study is the analysis in ovum donation cycles and neutralization of most embryonic factors, which could influence IVF treatments. Still, one of the major obstacles of any retrospective study is the limitation in controlling confounding factors which may influence outcomes. For example, in the present study women who had an LEI Pipelle procedure were found to be older than those who did not undergo the procedure. This parameter by itself could adversely influence pregnancy rates in this group, because a significant relationship between increasing recipient age and declining implantation was reported by several studies (25–27). This impairment of uterine receptivity with increased maternal age has been related to diminished uterine blood flow (28, 29), reduced progesterone sensitivity (30), and various histologic alterations, such as stromal angiosclerosis and extracellular matrix deposition (26, 28). However, other recent studies did not find an effect of recipient age on success rates (31). An additional disadvantage of cycles chosen for Pipelle scratch was a lower proportion of grade A endometrium in the LEI group. According to several studies, endometrial grade can significantly affect implantation and clinical pregnancy rates (32, 33). Also, the endometrium of recipients chosen for Pipelle scratch was thinner, although within normal accepted ranges (8.02 mm vs. 8.65 mm, respectively). In a previous study (34), we showed that more live births were observed in oocyte donation cycles for an endometrial thickness cutoff of 8.2 mm than for thinner endometrium or endometrium thicker than 9.6 mm, a finding supported by additional studies (19, 35). Finally, cycles in which Pipelle scratch was performed exhibited significantly higher numbers of prior oocyte donation failures. This implies a higher proportion of RIF cases in cycles chosen for Pipelle scratch, but this is the population of patients that have been offered LEI by all previous studies. A second group of confounding factors demonstrated in our study is the dissimilar management given to women in the Pipelle scratch group, which entailed higher doses of estrogens and more hysteroscopic procedures. However, this finding reflects the unfavorable prognostic characteristics in women chosen to undergo Pipelle scratch, as described above (older age, more failed cycles, and worse endometrial
DISCUSSION Our findings show that endometrial injury with the use of Pipelle scratch did not improve pregnancy and live birth rates in ovum recipients with RIF. To our knowledge, this is one of the first large-cohort published studies determined to examine the influence of LEI in oocyte donation recipients. LEI by Pipelle procedure was performed in 16.5% of the cycles. Of those 122 cycles, 46 pregnancies were achieved, including 39 clinical pregnancies and 29 live births. Our
TABLE 2 Clinical pregnancy rates [CPRs, n (%)] according to hysteroscopy findings with and without Pipelle scratch. Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 614)
Uterine factor
Total
All patients (n [ 736) CPR
Total
CPR
Total
CPR
None Fibroid uterus Endometrial polyp Intrauterine adhesions P value
436 254 30 16
136 (31.2) 76 (29.9) 8 (26.7) 1 (6.2)
80 34 3 5
20 (25.0) 18 (52.9) 0 1 (20.0)
356 220 27 11
116 (32.6) 58 (26.4) 8 (29.6) 0
.190
.012
.061
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION
TABLE 3 Clinical pregnancy rates [CPRs, n (%)] according to IVF cycle number with and without Pipelle scratch. All patients (n [ 737)
Pipelle scratch (n [ 122)
No Pipelle scratch (n [ 615)
Cycle number
Total
CPR
Total
CPR
Total
CPR
1 2 3 4 5 6 7 8 9 10 11 >3 cycles >4 cycles >5 cycles
293 205 103 57 35 20 10 7 4 2 1 136 79 44
90 (30.7) 60 (29.3) 37 (35.9) 15 (26.3) 8 (22.9) 4 (20.0) 1 (10.0) 3 (42.9) 1 (25.0) 1 (50.0) 1 (100) 34 (25) 19 (24.1) 11 (25)
7 17 29 25 18 11 6 5 2 1 1 69 44 26
2 (28.6) 7 (41.2) 11 (37.9) 5 (20.0) 6 (33.3) 2 (18.2) 1 (16.7) 3 (60) 1 (50.0) 0 1 (100) 19 (27.5) 14 (31.8) 8 (30.8)
286 188 74 32 17 9 4 2 2 1 0 67 35 18
88 (30.8) 53 (28.2) 26 (35.1) 10 (31.2) 2 (11.8) 2 (22.2) 0 0 0 1 (100) 15 (22.4) 5 (14.3) 3 (16.7)
Dain. Local endometrial injury and oocyte donation. Fertil Steril 2014.
condition). For example, women in the Pipelle scratch group received significantly more embryos in each cycle, even though in donor egg cycles, according to accepted guidelines, the age of the donor should be used to determine the appropriate number of embryos to transfer (36). In addition, women chosen for Pipelle scratch procedure also received more estrogen treatment, despite insufficient evidence in favor of that action (34, 37). Regarding anatomic factors, surprisingly fibroid uterus has been found to be a positive prognostic factor for the achievement of clinical pregnancy in the group that underwent Pipelle scratch. We note that myomectomy was performed at the time of hysteroscopy in those patients who were diagnosed with a submucous fibroid. If this is the case, the myomectomy was the major endometrial insult and not the Pipelle scratch. It would be incorrect to conclude that patients with fibroids do better with endometrial injury when a more significant intervention (myomectomy) was performed. Another point worth discussing is patient selection for the LEI. Prospective studies examining the influence of this procedure on the success of IVF treatment have used different inclusion criteria regarding minimum number of prior IVF attempts, varying from one to four (8–12). This is not surprising, because there are no formal criteria regarding the number of failed cycles for definition of RIF. According
to a United Kingdom survey performed in 65 licensed infertility centers, the definition of recurrent failure ranged from two to six prior treatment cycles, with three fresh IVF attempts being most frequently reported (2). In the present trial we tried to define the optimal number of failed cycles above which the Pipelle procedure would show its best effect. However, no significant benefit of Pipelle scratch was found in women with three, four, or five previously failed cycles. It is worth mentioning that in 79 women with four oocyte donation failures, the Pipelle scratch group showed clinical pregnancy rate of 31.8%, compared with 14.3% in cycles without Pipelle scratch. This difference did not reach statistical significance (P¼ .07), probably because of a relatively small number of cycles in each group. This may imply that the criterion for patient selection to undergo LEI could possibly be set to at least four previously failed implantation following ovum donation cycles, but clearly larger prospective studies are required to further evaluate this issue. Of note, as can be seen in our study, pregnancies can be achieved after multiple cycle failures (up to 11). Although many ART centers discontinue treatment after 3–4 failures, our findings confirm earlier reports that chances of achieving a live birth can be viable after several ETs (85.1% within eight treatment cycles) (38).
TABLE 4 Outcomes of oocyte donation cycles according to the interventions performed. Clinical pregnancy (n [ 221) Type of treatment None (n ¼ 392) Pipelle scratch only (n ¼ 42) Hysteroscopy only (n ¼ 223) Hysteroscopy and Pipelle scratch (n ¼ 80) P value
No clinical pregnancy (n [ 516)
Live delivery (n [ 170)
No live delivery (n [ 567)
n
%
n
%
n
%
n
%
126 13 56 26
32.1 31 25.1 26
266 29 167 54
67.9 69 74.9 67.5
98 10 43 19
25 23.8 19.3 23.8
294 32 180 61
75 76.2 80.7 76.2
.215
.324
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Fertility and Sterility® Another still unanswered question regarding LEI is the number of such procedures needed for an optimal outcome. A systematic review by El-Toukhy et al. described two randomized (n ¼ 193) and six nonrandomized (n ¼ 708) controlled studies comparing the outcome of IVF treatment in patients who had LEI in the cycle preceding their IVF treatment with control subjects in which endometrial injury was not performed (39). That investigation showed meaningful variability in the frequency of the intervention among the eight studies, with LEI performed only once before the IVF cycle in five studies, twice in 2-studies (9, 11), and on four occasions in one study (7). In the present study, we found no differences in the reproductive outcomes between cycles in which only Pipelle scratch was performed, those combining Pipelle scratch with hysteroscopy, and those with hysteroscopy alone. Because no randomized controlled studies have been published regarding the optimal number of LEI procedures performed in a single cycle, this question also remains unanswered. In conclusion, our findings have not demonstrated a positive effect of LEI on achieving pregnancy in ovum donation cycles, but a tendency toward improvement was observed when LEI was performed after four implantation failures. Although the sample size, 737 ovum donation cycles, is large, the retrospective nature of this analysis limits drawing solid definitive conclusions on the value of LEI. No beneficial effect was shown in combining Pipelle scratch with hysteroscopy procedure. This last point, as well as defining the optimal number of previously failed oocyte donation cycles for deciding on LEI, should be evaluated in large-cohort randomized prospective clinical trials.
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