The role of the endometrial cavity in IVF

Explained by: Olufemi Olarogun, FCOG, Dr., HART Fertility Clinic Cape Town
Category:
Related IVF videos:
From this video you will find out:
  • What are the most common causes of IVF failure?
  • What does the endometrial preparation for implantation look like?
  • Should fibroids be removed? The difference between cavity-distorting and non-cavity distorting fibroids
  • What is the data for IVF success for patients with polyps?
  • Why intrauterine adhesions should be always treated?
 

What role the endometrium plays in the implantation and IVF success?

In this recording, Dr. Olufemi Olarogun, FCOG, Reproductive medicine & surgery sub-specialist at HART Fertility Clinic, located in Cape Town, South Africa has talked about the endometrial cavity and its role in IVF success.

What role the endometrium plays in the implantation and IVF success? - Questions and Answers

I just removed a polyp 2 days ago, it was located on the back of the uterine wall, so it was pointless to remove it given the data showed in your presentation? Also, what if it grows back? Is it worth it to remove it? I never had IVF or miscarriages, I’m 43, and I will have donor eggs IVF hopefully within 2 months. Can I have a transfer after 1 or 2 months from the removal?

Yes, you can have your transfer two months after the removal. I would think that’s enough time, it’s a good thing you’re going with donor eggs. At 43, I think your chances are much better that way. The evidence is such that it depends again on the size of the polyp perhaps, but if it was picked up, as I’ve mentioned earlier, most IVF units will still remove the polyps. If it was picked up on the routine investigation, two centimeters, that’s a good size, it was picked up at the time you were being investigated for the cycle. I think that’s been a good move to have it removed by hysteroscopy, and if they don’t grow back so quickly, you’ve got yourself a bit of time to try and get your IVF cycle done after you’ve had the polyp removed.

Could removing a lot of small or big fibroids in the uterus (in the wall, near the uterine cavity) affect fertility? What is the best method to remove them and preserve fertility?

I’ve mentioned in my talk that you’re going to cause scarring of the uterine muscle. You’re going to a toss-up between the sizes of the fibroids and the closeness to the cavity. That’s what makes you decide whether you’re going to operate or not. Once you decide to operate, we follow the standard protocols, you go quickly, you try and prevent adhesions, but you are going to get sparring, so the question is whether if you operate on this uterus or you remove the fibroids: Are you going to convert that to a potentially fertile uterus to a non-fertile uterus. Generally speaking, we do a lot of myomectomies, we do a lot of fibroid removals, and following that, most patients conceive either on their own or following IVF, so if it is indicated, and it’s close enough to the cavity, yes, it should be removed. Potentially, it could affect fertility, but it shouldn’t actually. In other words, if you decide to remove it because you’re hoping that it would actually be better, so you’re expecting that your fertility chances would be better afterwards.

The best method to remove them depends on several factors, depends on the surgeon, the experience of the surgeon, it depends on the location, and the size of the fibroids. If the fibroids are in the cavity, the best way to remove them is through hysteroscopy, in other words going through the cervix, into the uterus, and removing them.

If they’re in the outside wall and they’re big, you have to go from the top, so in other words, you either have to do it laparoscopically, or you have to do a fairly big incision to remove them depending on how many you have. The decision on how it’s removed depends on the number of things. Obviously, on your doctor and the patient as well.

I want to start the IVF process and went for the first scan, and it was found that there was a 2.6cm submucosal fibroid. Is it necessary to remove the fibroid surgically before going for the IVF, or is the size insignificant?

It’s definitely significant, I mean 2.6 centimeters if it’s submucosal, it is significant. If you study the IVF process, I’m assuming, you’re talking about having gone through the stimulation process already. If you go through the stimulation process already, I would freeze the embryos, in other words, I would go ahead, do the retrieval, fertilize, and freeze and then go and deal with this fibroid before embryo transfer.

If it’s just in the walk-up stages of the IVF and the stimulation has not been started, then this should be dealt with or could be dealt with relatively quickly. Then go and complete the cycle, so it is necessary if you’ve got 2.6 centimeters submucosal fibroids, it would be necessary to have it removed before IVF.

Does a retroverted (tilted) uterus affect IVF success rates?

No, it doesn’t. I guess the only problem with it could be during embryo transfer, so in other words, when you’re trying to get the embryos with the help of the catheter, sometimes with a retroverted uterus, it might be a bit difficult to get into the cavity. Generally speaking, there are ways around that, we try, and we might put a little clip on the cervix and pull it down a bit. Once you get the embryo into the cavity, the chances are the same as if you have a normal uterus, so it’s just about getting the embryos into the cavity, and usually, with an experienced doctor, it’s not a problem. The short answer is no, but the only slight issue might be with getting the embryos into the endometrial cavity in a retroverted uterus.

I have regular ovulation, but often I have thin endometrium – 6 to 7 mm. Next month, I will have frozen ET. Is using estrogen support right after ovulation a good idea? If not, what can we do?

As I’ve mentioned 7 mm is something you don’t have to worry about, one of the things you can do is to use the support after ovulation and keep going with that until the point of the embryo transfer. Perhaps, even up to the point of a pregnancy test. Now, whether this would make a difference or not, there’s probably not enough studies to sort of confirming that but it shouldn’t do any harm, so it would be something that I would definitely consider in a patient who’s going for a frozen embryo transfer. I’m assuming this is a natural cycle, the other thing to try and do in this kind of scenario is to down-regulate the patient and then try and build the lining up individually, so you take over the building of the lining itself, and then, in that case, you can increase the level of estrogen significantly before you put the progesterone and try and get the thickness, so it depends on what kind of cycle your IVF center uses for frozen embryo transfers. If it’s a natural cycle, what you’re saying now makes sense to put it of estrogen in before to try and get it to improve.

I had open fibroid surgery 4 years ago (reason: uterus Myomatosus). New fibroids have grown back. Should I remove them again with an open myomectomy? How could I prevent them to grow back after surgery? How could I shrink them if I don’t want another surgery?

I’m assuming we’re not talking fertility here. If we’re not talking about fertility, it’s just the same in terms of following fibroids. There are other options, one of them is uterine artery embolization, which is available in most parts of the world where the blood supply to the fibroids are identified, and they are embolized, so we put little particles that block the blood supply. If it is for fertility, it becomes a little bit trickier, and you might have to actually have it removed again if it is in the cavity. If it’s close to the cavity or it’s in the cavity like the fibroids I had described earlier, then it makes sense to have a reoperation to have it sorted out again but do not wait. In other words, have it done, and go straight into IVF straight away.

Unfortunately, there is very little one can do to prevent fibroids from growing back. If you don’t want another surgery, you can perhaps consider using a medication like Zoladex, you can use a GnRH agonist that could help shrink the fibroids, but that’s only temporary. The moment you stop that, it will grow back again, so you might be able to shrink it for a short while and then go into an IVF cycle and get that done that way. It depends again on how big they are, how close they are to the cavity, so many other factors have to be considered. In short term, you might need re-operation if the fibroids have grown back in a place where it’s going to affect fertility, you can consider using GnRH to shink them.

If we think shrinking, it will then take it away from the cavity completely, which is unlikely, but there are very few other options. Uterine artery embolization, as I was talking about earlier, is reserved for women who are not trying to get pregnant at that particular point in time, and it does work effectively in shrinking the fibroids, but if you’re trying to conceive, then you’re left with either re-operation or having GnRH agonist to try, and shrink it initially. The question is whether that will shrink it enough for you to be able to do IVF successfully.

I had a sonohysterosalpingography, and they found both tubes blocked proximally. After a hysteroscopy, they saw the entrance of the tubes (there were holes), but they couldn’t say if they were patent or not. How can one diagnose hydrosalpinges? They told me I might have had spasms, but I took a medication to relax muscles. Isn’t laparoscopy a bit invasive? I’m worried about the adhesions.

Hydrosalpinges are diagnosed on hysterosalpingography, usually, proximal blockage means that it is right at the beginning of the tube, so even if there are hydrosalpinges, probably you won’t be able to go that far because the tube is blocked anyway at the beginning.

Hydrosalpinges refer to blockage distantly, so in other words, it goes into the tube, and then the fluid gets to the end of those tubes, and then it gets swollen there, it doesn’t come out because the tubes are blocked at the end. The hydrosalpinges are usually distal blockage rather than a proximal blockage, so if you go proximal blockage, it’s a bit difficult like you said, you might have to repeat the HSG at some point to see if it’s been opened. Did they try to put the catheter through to try and open the proximal blockage? If they did that then, you might be able to see on HSG that it’s opened. If they haven’t been able to successfully do that, then you’re looking at IVF, but if there’s a proximal blockage, then you do not have to remove the tubes, you can go straight into IVF.

There are two scenarios there, it’s possible that it is blocked proximally, and that might be the reason why it’s not going through. The second possibility is that you might have had a spasm, so the tube might actually just be in spasm at that particular point, and that’s why the dye didn’t come through. You’ve got two options here, either you repeat in a couple of weeks time, you can do another, or you can have a laparoscopy done, and at laparoscopy, we try and do what we call laparoscopy and dye, we introduce the dye through the uterus and then that will be a second test to try and check if the tubes are open. If the tubes are still blocked on laparoscopy and dye or repeated HSG, then it is clear that the tubes are indeed blocked, and you have to go for IVF, and if they are open at that point then you’ve got your answer.
Laparoscopy is a bit invasive because it needs general anesthetic and obviously, we need to make little holes in the tummy with the camera, but it’s also safe.

We do a lot of laparoscopies, for most fertility units, this is bread and butter as far as they’re concerned, they just do this all the time. It’s relatively safe, not without its complications obviously, so it’s still something one can consider if you’re trying to get the answers.

The fact that they gave you something to relax is indicated to try and see if that helps with the spasm, but that doesn’t always mean that there’s still no spasms. The fact that you used the medication and the tube remains blocked, does not mean that it still wasn’t spazzing, that’s why laparoscopy is indicated. The risk of adhesions with laparoscopy is not high, with a simple laparoscopy, the chances of causing adhesions are actually quite slim.

If you have endometriosis, which wasn’t diagnosed before, or you had adhesions previously, then it might cause more adhesions. But just a straightforward laparoscopy to check your tube, should not really induce too much adhesion, so I don’t think you need to worry too much about that.

Do hydrosalpinx justify the need to perform laparoscopy?

If you’re having hydrosalpinx, laparoscopy is almost always indicated. You need to then remove or at least block that hydrosalpinx. That’s usually done laparoscopically. As I said, it’s invasive, but it’s safe, and we do a lot of it, so I don’t think you need to worry too much about that.

Is there an age limit for treatment in your clinic (HART Fertility Clinic)? Is surrogacy or egg donation an option?

There is no age limit per Se, but obviously, above the age of 42, we would advise that you probably should consider egg donation, which is freely available here. Surrogacy is a little bit more tricky, it is available, you do have to have a high court judge saying that you can have surrogacy in the country, your doctor needs to write a letter, lawyers need to write a letter, so it’s a little bit more complicated, but it’s definitely possible, we can offer that service. Egg donation is very freely available, and so above the age of 42-43, you’re probably looking more at an egg donation cycle rather than a normal cycle, but it’s freely available.

How much is estrogen involved in the growth of fibroids and polyps? Is there a way to prevent the estrogen from having such an impact on these formations?

These are all estrogen-dependent tumors, so they all grow on the basis of estrogen, but you need estrogens everywhere else. You need estrogens on the breast, on the endometrium, on the skin, so you don’t really want to block the production of estrogens. It’s just that they have different effects on different organs, some good and some not so good in the case of polyps and fibroids in the uterus, but it’s not just these because every woman has estrogens but not every woman has fibroids and polyps.

There are other reasons why you would then develop fibroids, which are genetic factors and other factors possibly even in the diet, which we don’t know too much about. It’s not just about estrogen, so we can’t just shut down all the estrogen production because then you shut down all the good effects of the estrogen as well, so you can’t really do that. You have to look for ways of treating the condition rather than trying to just block the estrogens and the fact that you block estrogens does not mean that you’re going to prevent those conditions anyway. In some circumstances, we try and shut down estrogens completely, but you can’t do that forever, you can do that maybe for a short while because if you do that going forward then you have other factors as well like osteoporosis, cardiovascular disease, and all that comes with lack of estrogens.

For the egg donation process, what medication would you suggest to help improve the thickness of the uterus for a successful egg donation process? What is a good thickness size?

We aim for anything from 8 millimeters or above. You want to get at least over 7, or 7.5, 8 millimeters, and I’ve mentioned earlier that you need to stimulate with estrogens after downregulating, it gives you the ability to increase the dose of estrogen significantly, that’s probably the one proven way of doing it, you can give these estrogens vaginally, some people have used viagra to try and improve the lining of the uterus, and they feel the sort of non-proven things, but usually, it’s about increasing your estrogen levels and trying to get those levels to a level where the endometrium then responds to it. For instance, some women might require only 4 to 8 milligrams of estrogen per day to get things going, while in some women, you might have to go to 12 milligrams and stop to try and get the lining that you require. That’s how it works, you down-regulate, then you stimulate with estrogens until you get to the lining you want, and then you throw the progesterone, and so that’s what we use. There are other things one can consider other sorts of non-proven procedures to try and improve your chances of a thicker endometrium, but usually, it’s just the use of estrogens to try and get it going.

Do you think about the subserosal 5cm fibroid located in the isthmic area? There is only 3mm from the fibroid to the endometrial cavity. Does the fibroid makes implantation more difficult or influence somehow pregnancy?

That’s a tough one, and 5 centimeters is probably a cut-off where most people would think it might be worthwhile still removing that fibroid. If it’s close to the isthmic area, the other isthmic is there the tube should work from there if that’s the only problem. You should be able to get pregnant through the other tube if this is going to be a problem. 3 mm from the endometrial cavity is close, but it’s again not the closest. If you have an implantation difficulty. If you have tried IVF and it’s not working, or you’ve been trying to conceive for a while, and everything else is fine, so the sperms are okay, the tubes are fine. If the only reason they can find is this 5-centimeter fibroid, then I think that should be removed but only in those circumstances. Generally, this is probably not one that we will go after, but if you’ve had implantation failure with good blastocyst or good embryos and it’s not working or just trying to conceive a period, and it’s not working, then and if everything else is okay, it might be worthwhile going back to have this removed.

My gynecologist diagnosed me with a mild form of adenomyosis. What is the possibility that I also have endometriosis (on the ultrasound it is not seen)? Soon, I will have a hysteroscopy done. Do you suggest laparoscopy?

A mild form of adenomyosis in about one-third of patients would also have endometriosis. If you’re having a hysteroscopy done and you don’t have any symptoms at all, you can argue that you do not have to have a laparoscopy. But if you’re trying to get pregnant unsuccessfully, and especially if you have all the symptoms like painful periods or longer periods or just difficult periods, pelvic pain, pain during intercourse if you have any of that along with it, then you should have a laparoscopy. It’s difficult to answer not knowing what your gynecologist meant by a mild form of adenomyosis, maybe he’s not sure, and he wants to do a hysteroscopy to check, and that’s fine. If you’ve got symptoms of endometriosis, you should consider a laparoscopy at the same time.

Do you suggest checking the progesterone in the luteal phase before having IVF (egg donation)?

Not in egg donation because, in most cases of egg donation cycles, you are already down-regulated, so you’ve already got a GnRH agonist or something, so we don’t have to worry. The progesterone comes in when we introduce the progesterone., We don’t check the progesterone levels in the luteal phase, we just check the lining because basically, it’s an artificial cycle, you’re down-regulated and then stimulated with estrogens, progesterone is coming in just to get the lining ready at that particular point in time.

Authors
Olufemi Olarogun, FCOG, Dr.

Olufemi Olarogun, FCOG, Dr.

Dr. Femi Olarogun is a Reproductive medicine and surgery sub-specialist at HART Fertility Clinic, Cape Town. He qualified MBBS in Nigeria in 1990 and in 2010 obtained his FCOG fellowship qualification in South Africa. He practices in the private and public sector in Cape Town as well as Windhoek, Namibia. He has been Head of Firm for the Reproductive Medicine Unit at Groote Schuur hospital, the University of Cape Town since 2010. He also serves as a visiting lecturer in Botswana and Nigeria.
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Caroline Kulczycka is an International Patient Coordinator who has been supporting IVF patients for over 2 years. Always eager to help and provide comprehensive information based on her thorough knowledge and experience whether you are just starting or are in the middle of your IVF journey. She’s a customer care specialist with +10 years of experience, worked also in the tourism industry and dealt with international customers on a daily basis, including working abroad. When she’s not taking care of her customers and patients, you’ll find her travelling, biking, learning new things or spending time outdoors.

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