Endometrial lining is measured using the transvaginal ultrasound and is expected to be 8 mm or greater which is considered adequate thickness to conceive. An endometrial thickness of less than 7 mm has been associated with lower pregnancy rates, with almost no pregnancies observed with a lining less than 5 mm.
Women who have experienced early recurrent miscarriages or unexplained recurrent IVF failures tend to have thin endometrial lining, which can be caused by the following:
When thin endometrial lining is observed during an IVF cycle, the first option for treatment is adding oestradiol which may improve the overall endometrial thickness and outcome. Acupuncture and other relaxation techniques may be helpful in some cases, but large scale studies are needed to demonstrate a significant improvement with these treatment modalities. However, in few cases, the endometrial lining never reaches the acceptable thickness.
In cases of endometritis (infection of the uterine lining), an endometrial biopsy with documentation of chronic inflammation or endometrial cultures confirms the diagnosis, which requires antibiotic treatment. The chronic inflammation of the uterine lining should be treated with a combination of medications for at least 7 to 10 days. Patients can restart fertility treatment within one menstrual cycle if inflammation has subsided, and a repeat endometrial biopsy is not necessary to document this.
Intra-uterine adhesions or scar tissue can occur due to prior uterine cavity infections, pelvic inflammatory disease, multiple uterine procedures, prior termination of pregnancy or postpartum curettage of the uterine cavity. Hysteroscopic diagnosis and treatment of adhesions results in high pregnancy rates in many cases. Mild adhesions are easy to treat, but severe adhesions require a skilled hysteroscopic surgeon to attain the required result.
Hydrosalpinx leads to accumulation of toxic fluid inside the tube that can drain back into the uterine cavity causing disturbance in embryo implantation. It is recommended practice currently to excise such diseased tissue [removal of blocked tube(s) – salpingectomy] by laparoscopy.
Approximately 50-60% of all reproductive age women will develop benign growths of the myometrium, referred to as fibroids (myomas). Estrogen stimulates their growth and these tumors are rarely cancerous. They may be embedded in the uterine wall (intramural), on its outside (subserosal), in the uterine cavity (submucosal), on a short stalk (pedunculated), or in any combination of the aforementioned locations.
Fibroids, in most of the cases, present without any symptoms. However, there can be a variety of symptoms depending on their size, location and the absence or presence of complications such as heavy cyclical menstrual bleeding (menorrhagia) with menstrual pain (dysmenorrhea). Fibroids inside the cavity of uterus can cause erosion of the endometrial lining and produce irregular or continuous bleeding (meno-metrorrhagia). Other possible symptoms include pain with deep penetration during intercourse (dyspareunia), bladder irritability, rectal pressure, constipation and painful bowel movements (dyschezia).
Usually, the fibroids that impinge upon the endometrial cavity (submucosal), large intramural fibroids that block the openings of the fallopian tubes, or multiple fibroids in the muscle layer may adversely affect fertility. Surgery to treat fibroids can also affect fertility in many ways. If the endometrial cavity is entered during the surgery, there is a possibility of post operative adhesion formation within the uterine cavity. This should always be confirmed by a hysteroscopy or fluid ultrasound (hydrosonography) prior to beginning fertility treatment. For this reason it is important that experienced gynecological laparoscopic surgeons or reproductive medicine specialist such as Dr. Ripal Madnani, who are familiar with surgical techniques to limit blood loss and prevent adhesion formation, should perform myomectomy.
Fibroids are easily identified by simple vaginal–pelvic bimanual examination and transvaginal ultrasound. Magnetic Resonance Imaging (MRI) can be used to distinguish between fibroid tumors and a related condition called adenomyosis, in which diffuse or localized foci of endometrium is found within the myometrium. Given the often-diffuse nature of adenomyosis, it is difficult to remove surgically. This contrasts with fibroid tumors, which are well defined and are usually easily removed.
The treatment of fibroid tumors in infertility patients is surgical removal (myomectomy). Small, asymptomatic fibroids that do not disturb the endometrial cavity does usually not require treatment. Large fibroids and submucosal fibroids should be removed prior to embryo transfer to decrease the chance of implantation failure, miscarriage, pregnancy complications and premature labor.
Laparoscopic myomectomy requires 2-3 days for post-operative recovery, abdominal myomectomy usually requires 4-6 weeks of recovery time. When myomectomy necessitates or results in the uterine cavity being entered, it should be followed up with a hysteroscopy to rule out adhesions formation.
An endometrial polyp is the outgrowth of the endometrium like a skin tag inside the uterine cavity. It may be attached a small pedicle or have a broad base in endometrial cavity. The prevalence of endometrial polyp in reproductive-aged women is 20-25%. In 1% of the cases, polyp may have abnormal changes or can be cancerous. Therefore, in the opinion of Dr Ripal Modi, fertility specialist in Abu Dhabi, it is recommended that all polyps are removed before embryo transfer.
Polyps cause an inflammatory reaction inside the uterine cavity or cause irregular bleeding at the time of implantation. These effects can create a hostile environment for the implanting embryo and potentially cause miscarriage.
The best method to remove polyp is hysteroscopy. When pregnancy rates are compared before and after removal of endometrial polyps, higher pregnancy rates have been documented following surgical removal.
Intrauterine Adhesions (Asherman’s Syndrome)
Asherman’s syndrome is a condition characterized by the presence of adhesions in the endometrium. Adhesions can result from post-partum or post-abortion infection, postpartum curettage, and following uterine surgery such as removal of polyps and fibroids.
The severity of Asherman’s syndrome impacts clinical and pregnancy outcome. Moderate cases could potentially go unnoticed for a long period or until a woman wants to get pregnant.
Treatment involves a procedure called hysteroscopic lysis of adhesions, where a hysteroscope is introduced vaginally into the uterine cavity to allow direct surgical treatment of scar tissue under anesthesia. The purpose is to remove all of the scar tissue or at least as much as possible within the safety margin of the procedure.
Immunologic Implantation Failure & Endometriosis
Endometriosis causes chronic pain, distortion of pelvic structures, and infertility. Various studies suggest that endometriosis is related to a defects in functioning of the immune system. Impaired immune response in some women may result in unsuccessful removal of the endometrial cells from the pelvic area that may result in endometriosis. There are many substances like cytokines and natural killer cells which are involved in this disease pathophysiology.
Women with endometriosis might have an inflammatory reaction resulting in the release of toxic substances and activation of white cells. These toxins reduce the fertilization potential of the sperm and egg.
Moderate cases could potentially go unnoticed for a while. Increased Natural Killer Cell (NKa) activity has been observed in the peripheral blood and maybe in the endometrial linings of many endometriosis-afflicted women. Immunologic implantation failure is more likely to occur in such circumstances or up until planned pregnancy.
Selective immunomodulation with steroids and/or Intralipid can help to treat immunologic implantation failure and may lead to successful pregnancies in women who have increased NK cell cytotoxicity. Aspirin and heparin are recommended in women with anti-phospholipid syndrome and decrease the risk of having a miscarriage.
In cases of increased NK cell activity, Intralipid treatment prior to and after embryo transfer may be helpful, although it should be regarded as experimental treatment/research participation. Although intralipid looks to be a viable treatment, further scientific research is needed before it can be routinely used to treat implantation failure.
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