There are many steps involved in the development of a viable, normal pregnancy from fertility treatment. One step, which has been the focus of some unproven therapies (which can be dangerous and are expensive), is the area of implantation of the embryo. In the early days of fertility treatment, it was noted anecdotally that women often conceived quite quickly after a curette, whether following a miscarriage, or after surgery for another reason.
Ballarat IVF Specialists have been aware of reasonable quality research since 2010, which suggested that endometrial biopsy (or scratching), whether performed during a curette, or with a "pipelle" endometrial sampler was likely to increase implantation of embryos in subsequent cycles, either with natural conception or IVF.
The big challenge is to decide to whom, and when, endometrial scratching should be offered. For example, should it be offered to women who have failed to conceive after one, two, or more failed embryo transfers, unsuccessful ovulation induction, or women presenting with reduced fertility right from the start of treatment before IVF?
We also don’t know how long the effect lasts after the procedure, and hence how frequently it needs to be repeated.
The main advantage of endometrial biopsy is that it is safe, cheap, and easy to perform. Additionally, apart form the mild discomfort of the procedure, it has never been shown to cause harm to women, or adversely affect pregnancy rates.
So when do Ballarat IVF fertility Specialists offer a "pipelle"?
Well, it varies between patients, so you should raise this question with your fertility nurse, or your doctor when you see us next. I think most would agree that if you have had 3 embryo transfers with high quality embryos, and not conceived you should have a pipelle endometrial biopsy. In some other situations, for example in our older women, or those planning intrauterine insemination, it could be performed earlier.
Our feeling is that the effects probably last 2 cycles, but we have no hard evidence for this.
There is no doubt that at Ballarat IVF, we see endometrial scratching as an important part of fertility treatment for the relatively small number of women who don’t conceive after 2-3 embryo transfers. It is quite likely, however, that we will be offering the treatment to a wider range of women as we review more research data in the near future.
~ Dr Russell Dalton
Dr Russell Dalton was recently invited to present the Ballarat IVF perspective on ovulation induction and this included some interesting information which had recently been published from a US study comparing FSH, Letrozole & Clomid outcomes for women with unknown infertility being treated with IUI. This study is called the “AMIGOS Study".
(N Engl J Med 2015; 373:1230-1240 September 24,2015)
The most important adverse effect to be avoided when using "fertility drugs" is the generation of multiple pregnancy, as this type of pregnancy is associated with much higher rates of complications, and, unfortunately pregnancy loss.
When IVF treatment is used in Australia, because we almost always transfer a single embryo, the risks of multiple pregnancy are very low.
In the United states, 20% of triplet births are natural conceptions, 60% are from Ovulation induction, and 20% are from IVF treatment and multiple embryo transfer. If we compare 1960 to 2011, in the U.S., despite the birth rate going down , there were five times more triplet births in 2011.
The Multiple birth rate from IVF in Australia is 5% of pregnancies, compared to 31.6% in the United States.
In the AMIGOS study, the pregnancy and live birth rates were quite good, but the multiple birth rates were dramatically high, with one third of pregnancies in women using FSH being multiple, and 10% of pregnancies being triplets!
Even women using Letrozole in this study had a 13% twin pregnancy rate, emphasising the need for care with ovulation induction.
The other issue which this study raised, in Russell's opinion, was the importance of carefully assessing women with "unknown" or idiopathic infertility, as many will have endometriosis, tubal issues or lifestyle factors contributing to their fertility problems.
There are a small group of couples with "idiopathic" infertility who have an egg and sperm binding problem as a causative factor.
Finally, there is the issue as to what to do about actual unknown infertility.
The best options, in our opinion are:
• waiting a further period of time for natural conception, if the woman's age,
• the couple's life plans permit,
• moving straight to IVF with a single embryo transfer.
In situations of advancing age, IVF has the strong benefit of often providing fertility preservation in the form of vitrification (freezing) of spare embryos for use at a later time.
~ Dr Russell Dalton