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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 404-408

Effect of endometrial scratch using a Pipelle catheter on recurrent implantation failure with intracytoplasmic sperm injection


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Obstetrics and Gynecology, International Islamic Center for Population Studies and Research, Al-Azhar University, Cairo, Egypt
3 Faculty of Medicine (for Girls), Shebin Elkom Teaching Hospital, Al-Azhar University, Cairo, Egypt

Date of Submission30-Sep-2019
Date of Decision21-Oct-2019
Date of Acceptance19-Nov-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Eman M Malatan
Al-Azhar University, Faculty of Medicine, MSc of Obstetrics and Gynecology, Alkadi Street Sersena Alshohada Monofia 32841
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_136_19

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  Abstract 


Back ground In the last two decades, assisted reproductive technology procedures for culturing and transferring embryos have been continually improved, but the clinical pregnancy rate has not improved substantially over the last 10 years. The most important cause for implantation failure is embryo quality or uterine receptivity, but remains unexplained in many cases. About 75% of conceptus are lost before or at the time of implantation.
Aim This work aims to assess the effect of endometrial scratch (ES) using a Pipelle catheter on the outcome of intracytoplasmic sperm injection (ICSI) in patients with recurrent implantation failure.
Patients and methods The current study included 130 patients who were divided into two equal groups of 65 patients each. In the scratch group, endometrial local scratch using a Pipelle biopsy catheter on the mid luteal phase of spontaneous menstrual cycle before the ICSI procedure was performed, whereas the control group did not undergo ES. ICSI failure was recorded two or more times in each group.
Results In the current study, there were no statistically significant differences between the two groups in age, gravidity and parity, type, duration of infertility, and the number of previous ICSI trials. However, the BMI was higher in the control group. In the current study, there were no statistically significant differences between the two groups in basal hormonal profile follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin, estradiol, and anti-Müllerian hormone. In this study, there was highly significant increase in the pregnancy rate in the scratch group than the nonscratch group. The number of pregnant cases in the scratch group was 36 (55.4%), whereas in the control group, it was 21 (32.3%), with a highly significant P value of 0.008. In this study, there was no statistically significant difference between positive and negative pregnancy in the basal hormonal profile, except anti-Müllerian hormone and follicle-stimulating hormone levels, P values of 0.040 and 0.000.
Conclusion ES in the cycle before the ICSI cycle improved the chemical and clinical pregnancy rates compared with ICSI performed without ES in cases of recurrent implantation failure. It seems that increasing pregnancy rates could be because of the local inflammatory reaction elicited by the endometrial sampling procedure.

Keywords: endometrial scratch, intracytoplasmic sperm injection, Pipelle catheter, recurrent implantation failure


How to cite this article:
Hanafi MM, Rammah AM, Elkafrawy MA, Malatan EM. Effect of endometrial scratch using a Pipelle catheter on recurrent implantation failure with intracytoplasmic sperm injection. Al-Azhar Assiut Med J 2019;17:404-8

How to cite this URL:
Hanafi MM, Rammah AM, Elkafrawy MA, Malatan EM. Effect of endometrial scratch using a Pipelle catheter on recurrent implantation failure with intracytoplasmic sperm injection. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 12];17:404-8. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/404/278395




  Introduction Top


In the last two decades, assisted reproductive technology procedures for culturing and transferring embryos have been continually improved, but the clinical pregnancy rate has not improved substantially over the last 10 years [1].

The most important cause for implantation failure is embryo quality or uterine receptivity, but remains unexplained in many cases [2].

About 75% of conceptus are lost before or at the time of implantation [3].

Endometrial scratch (ES) or stimulation by a Pipple catheter causes a pseudodecidual reaction that enhances implantation. Some studies have confirmed that ES in the luteal phase of menstrual cycles improves implantation rates and pregnancy outcomes [3]. ES is supposed to improve the implantation rate by some theories.

Decidualization of endometrium might improve the transferred embryo implantation, the process of healing after local endometrial injury involves an inflammatory reaction mediated by cytokine interleukins, growth factors, macrophages, and dendritic cells, which are beneficial to embryo [4] implantation, trauma stimulates angiogenesis, and an induced injury can provide an angiogenic environment (interleukin 12 and interleukin 18), known to be crucial for anormal trophoblast invasion and retention of the embryo [5].


  Aim Top


This work aims to assess the effect of ES using a Pipelle catheter in patients with recurrent implantation failure (RIF) with intracytoplasmic sperm injection (ICSI).


  Patients and methods Top


This study is a prospective randomized-controlled study. The study was approved by the ethical committee of International Islamic Centre of Population and Research Studies and in accordance with the ethical protocol of Helsinki, 2013.

A total of 130 women (according to sample size equation) with RIF referred to the Assisted Reproductive Unit (International Islamic Center for Population Studies and Research Al-Azhar University) were screened. These women were divided into two groups:

The ES group (n=65) underwent ES by a Pipelle catheter at the midluteal phase of cycle preceding the induction cycle.

The control group (n=65) was observed without any intervention.

Inclusion criteria

The inclusion criteria were as follows: age 20–35 years, normal male factor, patients with a long ovulation induction protocol, transfer of two or more good-quality embryos in the current cycle, patients who had two or more unexplained RIF two or more, and normal findings of basic ultrasound.

Consent was obtained from all patients who participated in the study after an explanation of the purpose of the study was provided. Full data were collected from all patients including detailed personal, menstrual, and obstetric history. Also, general and local examination was performed and then a transvaginal ultrasound examination was performed for each studied patient.

The basal hormonal profile [serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels] on day 2 of the menstrual cycle was obtained in the cycle preceding ovarian stimulation. All data were recorded and analyzed.

Procedure

We performed the simple procedure of ES using a Pipelle biopsy catheter at the mid-luteal phase of the menstrual cycle that precedes the ICSI. A sterile Cusco speculum was gently inserted into the vagina, the cervix was wiped clean by a sterile saline-soaked cotton swap, and then an endometrial Pipelle disposable endometrial sampler, inserted gently through the cervix into the uterus, until touching the fundus, was rotated 360°, and moved four times up and down, followed by withdrawal of piston. This procedure was performed only in the ES group and then the long induction protocol was started in both groups (scratch and control). Then, ICSI was performed in the next cycle.

Outcome

The serum βhCG test was performed 14 days after embryo transfer and vaginal ultrasound was performed 14 days after βhCG being positive.

Statistical analysis

The recorded data were collected and then analyzed statistically.


  Results Top


Our study showed that there is highly significant difference between both groups as regarding pregnancy rate (55.4%) in endometrial scratch group in comparison with (32.3%) in control group also there is direct proportion between number of oocytes, transferred embryos and pregnancy rate also there is direct proportion between AMH and increased pregnancy rate ([Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6]).
Table 1 Comparison between the endometrial scratch group and the control group of demographic data

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Table 2 Comparison between the endometrial scratch group and the control group in the basal hormonal profile

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Table 3 Comparison between the endometrial scratch group and the control group in the pregnancy rate

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Table 4 Comparison between the scratch group with negative and positive pregnancy in terms of the basal hormonal profile

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Table 5 Comparison between the endometrial scratch group with negative and positive pregnancy in the number of transferred embryos

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Table 6 Comparison between the endometrial scratch groups with negative and positive pregnancy in the number of oocytes, fertilized oocytes, and day of embryo transfer

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  Discussion Top


The mean age of the studied women was 29.68 years in the ES group and 28.78 years in the control group; the mean BMI was 26.56 kg/m in the ES group and 27.95 kg/m in the control group; and the parity in both groups ranged from zero to two.

The mean duration of infertility was 8.97 years in the ES group and 8 years in the control group. In the scratch group, infertility was primary in 32% and secondary in 67%. In the control group, infertility was primary in 40% and secondary in 60%.

The mean level of FSH was 7.20 mlU/ml in the ES group and 7.22 mlU/ml in the control group. The mean level of LH was 5.62 mlU/ml in the ES group and 5.03 mlU/ml in the control group. The mean level of E2 was 71.82 pg/ml in the ES group and 59.87 pg/ml in the control group. The mean level of prolactin was 13 ng/ml in the ES group and 13 ng/ml in the ES group. The mean level of thyroid-stimulating hormone (TSH) was 2.03 µIU/ml in the ES group and 2.01 µIU/ml in the control group. The meal level of anti-Müllerian hormone (AMH) was 2.14 ng/ml in the ES group and 2.24 ng/ml in the control group.

In the current results, there were no statistically significant differences between the two groups in age, parity, type, duration of infertility, and the number of previous ICSI trials, whereas the BMI was higher in the control group.

There were no statistically significant differences between the two groups in number of oocytes, fertilized oocytes, number of embryos, and day of embryo transfer.

In this study, there was no statistically significant differences between the two groups in basal hormonal profile FSH, LH, TSH, prolactin, E2. and AMH.

Our study results showed that the biochemical and clinical pregnancy rate in the scratch-treated patients was higher than that in the control group. The number of pregnant cases in the scratch group is 36 (55.4%), whereas in the control group, it is 21 (32.3%), with P value 0.008, which is a highly significant value. Our study is in agreement with the result of Hilton and colleagues [6], who performed ES 5–10 days before the start of gonadotrophin in the ICSI cycle compared with no scratch. They studied 51 women: 25 in the ES group and 26 in the control group. The primary outcome was that the clinical pregnancy rate was 52% in the endometrial injury group and 46% in the control group (P=0.45); the live birth rate was 52% in the EI group and 35% in the control group.

Also, our study is in agreement with Mahran and colleagues [7], who studied 400 patients undergoing their first ICSI trial to undergo endometrial injury in the luteal phase of the preceding cycle (intervention group) or no treatment (control group) and reported that implantation and live birth rates were significantly higher in the intervention group compared with the control group (22.4 vs 18.7%, P=0.03); there was also a significant reduction in the miscarriage rate in the intervention group (4.8 vs 19.7%, respectively, P<0.001).

In the current study, there were no statistically significant differences between the two groups in basal hormonal profile FSH, LH, TSH, and AMH, whereas Prolactin hormone was significantly increased in the scratch group and E2 was highly significant in the scratch group.

The present results showed that the biochemical and clinical pregnancy rate in the scratch-treated patients was higher than that in the control group: 36 (55.4%) in the ES group vs 21 (32.3%) in the control group, P value of 0.008.

Our study did not show statistically significant differences between both groups in the number of retrieved oocytes, fertilization rate, and transferred embryo. This is in agreement with Gibreel and colleagues [8].

Also, the pregnancy rate was directly proportionate to the number of the used oocytes, fertilized oocytes and embryos, which is in agreement with Ottosen and colleagues [9], who found that women with more oocytes had higher chances of pregnancy.

Also, Salumets and colleagues demonstrated that the chance of pregnancy increases with the number of embryos transferred [10]. In our study, we showed that there was an increase in pregnancy rates in patients with AMH levels between 1 and 4.2, P value of 0.000, and FSH levels from 4 to 10, P value of 0.040, than other patients.

Our study is in agreement with Choi and colleagues [11], who evaluated 370 women and found statistical significance in the number of oocytes retrieved and clinical pregnancy rates. Wang and colleagues reported that women between 34 and 41 years of age with higher serum AMH concentrations are associated with greater chances of pregnancy (P<0.01) [12].


  Conclusion Top


ES in the cycle that precedes the ICSI cycle improves the chemical and clinical pregnancy rates compared with ICSI performed without endometrial injury. It seems that increasing pregnancy rates could be due to the local inflammatory reaction elicited by the endometrial sampling procedure. Also, a Pipelle catheter is cheap and easy to use used in the outpatient clinic without anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Margalioth EJ, Ben-Chetrit A, Gal M, Eldar-Geva T. Investigation and treatment of repeated implantation failure following IVF-ET. Hum Reprod 2006; 21:3036–3043.  Back to cited text no. 1
    
2.
Rumack C. Diagnostic Ultrasound. St Louis, MI: Mosby; 2004.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
Safdarian L, Movahedi S, Aleyasine A, Aghahosaini M, Fallah P, Rezaiian Z. Local injury to the endometrium does not improve the implantation rate in good responder patients undergoing in-vitro fertilization. Iran J Reprod Med 2011; 9:285.  Back to cited text no. 4
    
5.
Parsanezhad ME, Dadras N, Maharlouei N, Neghahban L, Keramati P, Amini M. Pregnancy rate after endometrial injury in couples with unexplained infertility: a randomized clinical trial. Iran J Reprod Med 2013; 11:869.  Back to cited text no. 5
    
6.
Hilton J, Liu KE, Laskin CA, Havelock J. Effect of endometrial injury on in vitro fertilization pregnancy rates: a randomized, multicentre study. Arch Gynecol Obstet 2019; 299:1159–1164.  Back to cited text no. 6
    
7.
Mahran A, Ibrahim M, Bahaa H. The effect of endometrial injury on first cycle IVF/ICSI outcome: a randomized controlled trial. Int J Reprod Biomed 2016; 14:193–198.  Back to cited text no. 7
    
8.
Gibreel A, Badawy A, El‐Refai W, El‐Adawi N. Endometrial scratching to improve pregnancy rate in couples with unexplained subfertility: a randomized controlled trial. J Obstet Gynaecol Res 2013; 39:680–684.  Back to cited text no. 8
    
9.
Ottosen LD, Kesmodel U, Hindkjær J, Ingerslev HJ. Pregnancy prediction models and eSET criteria for IVF patients–do we need more information?. J Assist Reprod Gen 2007; 24:29–36.  Back to cited text no. 9
    
10.
Salumets A, Suikkari AM, Mäkinen S, Karro H, Roos A, Tuuri T. Frozen embryo transfers: implications of clinical and embryological factors on the pregnancy outcome. Hum Reprod 2006; 21:2368–2374.  Back to cited text no. 10
    
11.
Choi T. Dimethyl sulfoxide inhibits spontaneous oocyte fragmentation and delays inactivation of maturation promoting factor (MPF) during the prolonged culture of ovulated murine oocytes in vitro. Cytotechnology 2011; 63:279–284.  Back to cited text no. 11
    
12.
Wang S, Kou Z, Jing Z, Zhang Y, Guo X, Dong M et al. Proteome of mouse oocytes at different developmental stages. Proc Natl Acad Sci 2010; 107:17639–17644.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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