In this webinar, Dr Harry Karpouzis, MD, Founder & Scientific Director at IVF Pelargos Fertility Group, Athens, Greece has discussed endometrial factors that cause recurrent failed IVF attempts. Dr Karpouzis has also, provided how to diagnose it and what are the treatment options.
The success of an IVF depends on the embryo, which is a very important factor. It includes the quality and the chromosomes of the embryo, but it also depends on the endometrium, the lining of the womb and medical factors like a thyroid gland, immunological factors, and endometriosis. The endometrium is not considered like the eggs, the embryo, or the sperm, but it is equally significant. Many proteins and molecules play a role in the implantation of the embryo, but their coordinated contribution is very poorly understood. Nowadays, molecular biochemistry and genetics help us a lot to understand it.
The most common endometrial factors that can cause recurrent implantation failure and the easiest to understand are the anatomic factors. These are polyps inside the endometrium, a fibroid protruding inside the endometrium, a septum, a congenital septum or adhesions called Ashermans. All those factors play a very important role in the implantation of an embryo. We can diagnose those with the 3d ultrasound, which is a non-invasive procedure, and hysteroscopy, which is an invasive procedure, it’s diagnostic but at the same time can be used to treat patients.
Polyps are very common, and 10% of the general female population has them. Some research shows that they are more frequent in women with endometriosis, and they can affect fertility, both spontaneous and IVF implantation of the embryo with different factors:
How can polyps be diagnosed?
Fibroids are also very common, they occur in around 3-10% of women of reproductive age. In African origin women, the percentage is even higher. We can diagnose them with 3D ultrasounds or MRI if there are a lot of fibroids, and it’s difficult to get a clear picture of where exactly each of the fibroids is located. The data and the research shows that fibroids that are close to the cavity interfere with the cavity or distort the cavity, and it can be associated with recurrent miscarriages. Some research shows that 8.2% of women with recurrent miscarriages have a fibroid, which is close to the cavity and affects the cavity. Some fibroids protrude inside the cavity, and those are the submucosal fibroids. Some fibroids are inside the womb muscle, and they are the neural ones, and there are also the subserosal ones in the serosa. There is clear evidence that the submucosal fibroids need to be removed before IVF because they can impact fertility, they can affect implantation rates, and they can significantly reduce the outcomes.
It is a bit more difficult to decide what to do with intramural and subserosal fibroids, generally, intramural fibroids which are less than 4 or 5 centimetres in size and are not protruding from the cavity inside, are better to remove at least in the first attempt of IVF. There are quite significant data that says they might not play an important role. If the fibroids are more than 5-6 centimetres, it needs to be removed unless there is a very specific reason for not doing that, for example, in a medical region that affects a woman’s health.
Fibroids with more than 50% projection in the cavity need to be removed. On the other hand, removing fibroids with less than 50% projection in the cavity is more complex, and many factors need to be considered, such as hysteroscopic assessment, woman’s age, if there were any previous implantation failures or surgeries, AMH levels,
According to Dr Karpouzis, when we are dealing with submucosal fibroids, they need to be removed by hysteroscopy and if they are more than 3 centimetres, it’s better to use GnRH analogues before to reduce their size a bit and then remove them. GnRH help to avoid the risk of the second stage is reduced. Before giving GnRH analogues, it is necessary to consider other factors like AMH, age, etc. If there is a low AMH and advanced maternal age, and we are dealing with a poor responder, it would be better to retrieve the eggs first. Then go ahead with the removal of the fibroids because GnRH can down-regulate the ovaries and make them more difficult to stimulate them again after that.
Intramuscular or big subserosal fibroids need to be removed with laparoscopy. If they are more than 50% submucosal, then hysteroscopy can be done, but it needs to be done correctly without compromising the cavity, technically, it is a difficult operation. If less than 50% is protruding inside the cavity, then possibly the best thing would be to remove it with laparoscopy and combine it with a hysteroscopy.
The septum is usually congenital, it can mechanically affect the implantation, can reduce the size of the cavity, affect the sperm transporter, can be a consequence of inflammation as well, and can increase the miscarriage rate. Various research shows septums can increase the miscarriage rate between 20-40%. They can also cause preterm deliveries, increase the rate of caesarean section, and breach the position of the baby. It is sometimes difficult to find out if it is a septate or bicornuate uterus, and the management is completely different for each. Therefore, using 3D ultrasound, MRI, HSG, Hydrosono, HyCoSy, and hysteroscopy, is the gold standard to check what is happening.
The septum can be removed with the use of a Hysteroscopic Metroplasty resectoscope, whether with scissors or a laser. When the embryo transfer is delayed, it would be preferable to take antibiotics and do some hormonal treatment with estrogen to keep the septum from coming back. Sometimes also intrauterine device (IUD) can be used, we can use estrogen priming a go ahead with IVF after the removal of the septum.
Adhesions or Ashermans’ syndrome, most of the time, occur post-surgery, or after infections. It’s suspected by ultrasound when the lining of the womb is not a good size or it doesn’t look healthy, it’s not trilaminar. Also, colour Dopplers can help in finding out, but the gold standard is hysteroscopy. Adhesions can cause infertility, recurrent pregnancy loss, and preterm deliveries, it is very difficult to deal with them, and when we see them, we try to separate the adhesions. We do that with hysteroscopic adhesiolysis, antibiotics, estrogen treatment, and IUD, several studies say that the use of vitamin E can be helpful, with Sildenafil (Viagra), there is no clear evidence behind that. The last thing we can do with the endometrium if even after hysteroscopic adhesiolysis is not increasing in size is using a growth factor called Granulocyte colony-stimulating factor (G-CSF), which can sometimes help in increasing the thickness, but nothing can guarantee that endometrium will be healthy. The last resort is surrogacy.
One of the most common reasons for a thin endometrium is Asherman’s syndrome, it can also be an infection, either an acute one or a chronic infection. It can also be associated with tuberculosis sometimes and in many cases, it is related to medication like Clomid, for example, we know that it can reduce the thickness of the womb, if it does, we need to change medication. There are cases with no history of D&Cs or myomectomies, infections and et the endometrium is not getting thicker than 7 millimetres, it is quite common in IVF. Most of the time, thin endometrium can also be associated with poor glandular epithelium, high uterine blood flow impedance, decreased growth factors and cytokines.
Some data says that the cut-off limit is 7 millimetres and there is a significant drop in the probability of pregnancy below 2.4%. Another research showed that the ideal thickness is between 9 and 14 millimetres, and when they are compared to that 7-8 millimetres, the pregnancy rates are higher. However, pregnancies have been reported with thinner endometrial thickness of less than that. It’s not only the thickness, other factors need to be taken into consideration as well, for example, if it is trilaminar endometrium, if it is hyperechoic and if there is any blood flow inside the endometrium. We can check that with Colour Dopplers, with 3D ultrasound, we can set the endometrial volume. There is a lot of research that shows that all these factors can play a role.
The first thing that can be done if we are dealing with a thin endometrium is to find out if there is an anatomical reason, like Asherman’s syndrome, or adhesions, we use hysteroscopy for that. If there are adhesions, we can divide them.
When we do the hysteroscopy, many times it can also be associated with chronic endometritis. Vaginal cervical cultures are not very accurate when we are looking for an infection inside, we can take endometrial cultures, and we can do it either as an outpatient procedure or at the time of hysteroscopies like ERA test or ALICE test. There are specific signs during hysteroscopy that can show chronic endometritis, such as hyperaemia or oedema (thickness of the endometrium) and micropolyps. All those factors have a high sensitivity, specificity and positive and negative predictive values of the hysteroscopy of about 92.7%, and if we also see micropolyps inside, it further increases it, 63.7% of the cases that we have made the diagnosis with hysteroscopy are confirmed with histology.
The most common bacteria are streptococcus, E-coli, enterococcus, ureaplasma, and chlamydia only 2.7%. There are several treatment options to deal with bacteria. Treatment with Doxycycline for 14 days, if it’s a culture that confirms that we are talking about the gram-negative bacteria, then we give Ciprofloxacin for 10 days, if it is a gram-positive, it’s Amoxicillin plus Clavulanic for 8 days. It’s possible to use a combination of those. In the case of a negative bacterial sample but positive histological and hysteroscopic diagnosis, we use Ceftriaxone, Doxycycline and Metronidazole for 14 days. Therefore, antibiotics can help a lot if we have a diagnosis of chronic endometritis.
Herpes can affect the endometrium, and some data says that the presence of HHV-6A DNA (herpes DNA in endometrial cells) can alter the hormonal environment. There is data that shows that estradiol levels are higher, which are most probably favourable for herpes. With that specific herpes, the immune environment is altered. Some uterine natural killer cells (NK) are lower, but they get higher activation. The Interleukin 10 (IL-10) is elevated, and the TH1/ TH2 ratio is increased. We know that this ratio is associated with infertility in reproductive immunology.
We know that some medication can affect the thickness of the endometrium when we do a frozen embryo transfer, but we don’t down-regulate, most of the time, it doesn’t play any role, but some people react differently. Estrogen (Progynova) protocols can also affect the pituitary by down-regulating, and again, this can negatively affect the endometrium. When we start with estrogen, we know that sometimes ovulation can happen, and this can cause problems in the implantation. Clomid can also affect the thickness, so sometimes, we need to change the medication. Sometimes, it is better to give dermal patches instead of oral medication because sometimes people react better to them.
If we don’t have any obvious reason for thin endometrium and we do a hysteroscopy, and the result is normal, it’s best to do a natural cycle tracking. It means that we observe how the endometrium is increasing in the natural cycle, and we see sometimes that the endometrium may increase when the follicle grows more than 18-24 millimetres in size.
G-CSF, growth factor increases the mesenchymal and haematopoietic stem cells which means that it causes a regeneration of the endometrium. In 2011, a lot of data was collected that shows improvement when everything else has failed. We use it in cases of very persistent endometrium that is not getting thicker before we decide to go to surrogacy.
The endometrium is related to hormones, and sometimes estrogen and progesterone are enough for implantation. We need to have good estrogen priming before we start the progesterone and there is data that shows that the ideal is 12 to 18 days of estrogen, less than 9 days is not enough. Then we give progesterone which prepares the endometrium for implantation and the implantation happens about 7 days after the trigger after the ovulation, and the implantation window can vary about 2 days. Progesterone levels are very important as well before the embryo transfer. When we are talking about the frozen cycle, then progesterone levels ideally should be more than 12.
It was discovered in 2011, it shows the implantation window before it happens, about 8-10 days post ovulation. Molecular biology has identified a unique genomic signature of endometrial receptivity, and it diagnoses the molecular status of the receptive endometrium according to its transcriptional signatures regardless of its histological appearance. It analyzes 238 genes, and we can find out if the endometrium is receptive after 5 days of progesterone, before or more than that, it can be pre-receptive or post-receptive. ERA test is combined with the ALICE test, which shows if there is chronic endometritis. The EMMA test shows if there are good bacteria in the endometrial microbiome. These tests are very important in cases of unexplained failures without any other obvious reasons and good embryos.
It can affect the endometrium too, it causes a hostile environment that can affect implantation, and it doesn’t only affect the quality of the eggs. Usually, when we suspect endometriosis, it is either good to down-regulate the ovaries and suppress the disease before the transfer or even operate in cases of severe degree. Is it better to operate before or after the egg retrieval? That depends on many factors, before an embryo transfer, if we have frozen embryos, we need to down-regulate and suppress the disease, we need to create a healthy environment before we do the transfer. To identify the endometriosis, we can do laparoscopy, or sometimes there are some new tests like the ERA test, where a specific protein BCLX6 is identified. If the result is positive, women are 5 times less likely to succeed in IVF. That way we can identify endometriosis without the need for a laparoscopy.
Even if the embryo is thoroughly investigated, we need to remember that it’s not the only factor. The endometrium can play a very important role as well in the whole process of implantation window, bad hormones, receptors, cytokines, genes, proteins, all those things play a role as it’s the coordination of them that makes the implantation happen, it’s not completely understood. Molecular biology and genetics help a lot to understand that with the new tests, but there is a long way to go. The most important thing is to have a personalized approach and keep in mind unexplained infertility is less and less unexplained.
We have a fibroid, as we said, that is intramural, so they start from the muscle. Some of those fibroids can protrude inside the cavity. Half of them can be inside of the womb muscle, half of them go inside the cavity. Some of them are mostly inside the womb muscle. It is less than 50%, and some are more than 50% percent inside the cavity. They are not completely inside the cavity. It’s difficult on how to remove them hysteroscopically, laparoscopically, that’s what I mean.
It’s exactly that. If we have a very poor responder with very low AMH, and someone is close to 40-42, we understand that the laparoscopic removal of the fibroid would mean another 6 months before she tries again. This affects fertility to a very big degree after 40. We know we have a very steep reduction in fertility. Sometimes, we need to evaluate all the factors and see if it is worth doing that for a fibroid, which is intramural. Regarding the submucosal fibroids, we have clear evidence, so we need to take all the factors, this is what I mean when I talk about age.
When it comes to the first question, it’s a difficult question, all those tests cost a lot of money, you may need to pay for another IVF, for example, to do all those tests, and we don’t use them for everyone. Another reason is that we are talking about invasive tests sometimes as well, and we don’t do all those tests if we don’t have any reason suspecting that something is wrong. It increases a lot of the cost.
Some of those procedures and tests are invasive, we need to take biopsies, we need to do laparoscopies, hysteroscopies. If we know that we have very good chances of about 74% of achieving the pregnancy, then I don’t know if it would work to do those tests for everybody. If we have an unexplained failure, then yes, we need to personalize each patient and check all of those things.
Yes, they can be removed without affecting fertility. Generally, if the surgery is done correctly, it doesn’t affect fertility. If we manage not to breach the cavity, then, of course, there’s no problem. The question is: do those need to be removed or not? As I’ve said, for a fibroid that is small in size that is close to the cavity, it is a difficult question to answer, and we would need to consider lots of factors.
If they are just touching the cavity without protruding, maybe I wouldn’t remove them from the first IVF if I knew that the cavity is free and no fibroids are protruding inside that, and it looks healthy. Yes, they can be removed if the surgery is done correctly.
No, hysteroscopies will not damage the endometrium. Invasive hysteroscopies like adhesiolysis, removal of submucosal fibroids that are done over and over again will always be the cause of creating chronic endometritis, some adhesions, or scar tissues. It depends on the technique, it is very important the surgeon is experienced, not only that because reproductive medicine is a completely different thing than just treating for symptoms. The diagnostic hysteroscopy will not affect it, it will not cause damage to the endometrium.
It’s a combination, as I’ve said, it’s the thickness, the blood flow. If the thickness is okay, the endometrium is trilaminar, then sometimes, we don’t look for blood flow. If the thickness is not ideal, then we need to check to see if it is also combined with reduced blood flow or not. The blood flow is checked with Color Doppler, so with ultrasound and if we find out that there’s no blood flow inside the endometrium, then we suspect that something is wrong, so then we need to go ahead with the hysteroscopy and see what’s the reason that it’s causing that.
All those things that we are discussing are things that we try to do to improve the endometria. Usually, the endometrium doesn’t need any improvement, it goes thicker by itself if everything is nice and everything is normal, and we don’t have any issues. In a natural cycle or estrogen cycle, the endometrium will get thicker if it is normal. If there are problems with endometrium thickness, for example, you should check the growth factor with the hysteroscopy. Some research talks about Sildenafil, Viagra, all those things that can affect it, but to be honest with you, the endometrium is a very difficult factor to treat, and most of those treatments do not have conclusive evidence behind it. They have important evidence that they may help.
Adenomyosis is a difficult thing as well. Most of the time, it cannot be operated on, so the only option is to try and make it better with GnRH. Many times they do not help. In adenomyosis, you cannot judge the excess of it from an ultrasound. When you suspect endometrial regions as well is hysteroscopy and check if the endometrium is affected as well, and the part of the adenomyosis just try to regulate, this may minimize a bit the thickness the muscle of the womb, check with a hysteroscopy to make sure that you don’t have any problems inside the endometrium and this is what you can do. I wouldn’t be able to give you a figure of how thin the junctional zone should be.
First of all, every woman who is trying to get pregnant should take folic acid, which protects from birth abnormalities of the baby. There are many multivitamins for men and women on the market that advertise they can improve the egg quality. There is no strong evidence behind it, but there are some vitamins that can be used. For example, for PCOS patients, it’s inositol, or for poor responders – the DHEA. There are many of those in the market, depending on the case, you don’t have anything to lose by making sure that you take a bit of vitamin D, folic acid and taking the rest of the things that are needed. To make sure that you are well prepared for the embryo transfer. Vitamin E can help, as well.
That’s a very difficult question, we need to go through the whole medical history. In your case, I would do a natural cycle to see what is exactly happening in the natural cycle. Most of the time, this is a matter of uterine defect, which means it is progesterone-related. Unless there is a reason that is causing the bleeding, so one of the things that I would first check is to make sure that there are no adhesions with hysteroscopy. You need to make sure that everything is okay inside, and then depending on what is exactly happening on a natural cycle, maybe I would try to do a transfer of natural cycle, not a hormonal cycle. Sometimes, in cases like it’s related to that, it can help.
Fibroids are estrogen-related, so pregnancy can increase them because, in pregnancy, estrogens are increased. IVF increases the estrogen, so yes, at the time of stimulation, it can get increased. Usually, they are not increased a lot, and they go back to normal after we start the hormones, but sometimes we do see that we have an increase in their size. Rarely, it is something that causes problems.
It’s the policy of each clinic. We do a lot of blood testing during our IVFs, and so at the time of the stimulation, we check the progesterone as well. Some data shows that we need to have specific levels, they are not completely indicative of the progesterone, that’s true.
Some other data shows that if the progesterone is less than a specific level, the chances are getting less in a frozen cycle and higher from a specific level in the fresh cycle, the chances are reduced, so why not check it.
This is again a difficult question, yes, you could do it if we have a recurrent failure of implantation. The thing is that reproductive immunology is a very complicated and difficult thing, not all people know what’s the exact significance of each of those factors. Steroids coverage, for example, which is a very cheap medication together with a combination of intralipid infusions covers about 90% percent of the cases of the immunological factors that can affect the implantation, and it cost much less than the testing, on a protocol that is given correctly. There is another 10% that may need extra treatments like immunoglobulin infusion and things like that.
Yes, it is a test that can be used if we are planning to properly evaluate it and properly give other treatments than intralipids and steroids because those can be given without the testing that costs a lot of money.
We don’t regularly do it unless there is a case of repeated failure. We usually combine it with a test which is called ALICE, which is the same as the ERA test. The biopsy can be taken either at the time of hysteroscopy or as an outpatient procedure. If we do it at the time of hysteroscopy, we don’t repeat the hysteroscopy, but as an outpatient just to make sure that it hasn’t shown the histological signs again, yes, we can do it. The truth is that when we cover for the specific bacteria with triple antibiotic or the specific antibiotic for a specific period, we don’t usually repeat the test, we just give the antibiotics, and we do the embryo transfer. In some cases where we have an unexplained failure, we check it.
It doesn’t go like that, it can be associated with many other things as well. Yes, you may have herpes inside without really having symptoms of herpes outsider, so it can happen. It doesn’t mean that it’s related only to that. There are blood tests that you can do to see if you have herpes. If you have any immunity for herpes if you had it in the past, or if you have it now, there are antibodies that you can check. This is for genital herpes, and this is for herpes in the lips. For specific herpes, you can check for those in endometrial culture.
Endometriosis can do many things, it can also affect the tubes either by distorting them with adhesions or anything like that, but it can cause a hostile environment too. The tubes are a patent, and they communicate with the cavity, they communicate with the womb, and if there is endometriosis inside the cavity, this hostile environment can affect the transfer of the sperm, and anything that can play with the tubes can cause and increase the risk of an ectopic pregnancy.
Endometriosis can cause increased immunological activity, natural killer cells, inflammation inside the womb. It doesn’t usually cause a reduction in uterine thickness unless it is related to some surgery inside the cavity that can cause that as a medical consequence.
There is some data for that as well. We use it as well, but in comparison to the CGSF and the PRP, the data and the evidence that I’m familiar with, and we usually prefer it in comparison to the PRP, but yes, it can be used, and there is research that shows that it can help, there is no significant difference in comparison to CGSF though. Those 2 are used as a last resort before we go through surrogacy and things like that, so you can try that.
It is not possible to operate the adenomyosis. Down-regulation with GnHR can help a bit to suppress the disease. Usually, mild adenomyosis does not affect implantation, but many times it is associated with endometriosis. We have seen that people who have adenomyosis also have comorbidity factors. Endometriosis can affect it.
Embolization can affect your own eggs, can sometimes cause premature ovarian failure, so it’s not the best thing to do for a 5-centimeter fibroid. If it is just a 5 centimeters fibroid that is not affecting the endometrium, I wouldn’t remove it or anything like that. It depends on the location of it, though. The hysteroscopy should be done to make sure that it doesn’t affect the cavity, it is something that can be done, and then you need to make a very good decision if you need to remove it or not. If it doesn’t affect the endometrium and it’s just 5 centimeters in size, I could go ahead with a transfer.
It depends sometimes, this happens in patients with polycystic ovaries. If you are talking about having an ovarian stimulation and the endometrium was 11 and then 8, then maybe something has gone wrong with the protocol or doses or premature ovulation, for example, has happened.
There could be many things. A drop in the endometrium sometimes may make us think about freezing the embryos. If you have embryos in the end and do the transfer in a frozen transfer after we create a normal endometrium that is increasing.
Endometrial hyperplasia, most of the time, is related to obesity, for example, and increases weight. If it is a histological diagnosis, we need to make sure that it is not associated with any activity. It can be a precancerous lesion as well, it depends. If it’s just simple endometrial hyperplasia sometimes, you don’t need to do anything. If it is complex hyperplasia or has abnormal cells, for example, the Mirena coil, increased progesterone doses are things that you can consider.
When it comes to endometrial hyperplasia outside the stimulation to affect the embryo implantation, then no. If you are talking about the endometrium that is getting very thick at the preparation time, you need to make sure that there is no hidden polyp. Hysteroscopy would be good to make sure that it’s nothing like that. The second thing is that if the endometrium gets more than 15-16 millimeters, some research shows that it can reduce the chances. The ideal thickness at the time of the stimulation is between 9 and 14.
Not to my knowledge that it really can make a significant difference to be taken before the embryo transfer to increase the uterine lining.
We do give it to poor responders, especially and women that have problems with quality embryos, we use it. Some data suggests it can help.
Adrenal progesterone is not getting absorbed in a balanced way sometimes. This can cause issues with the levels of progesterone. That’s why we usually prefer in our clinic to give a higher dose of progesterone. We can make sure that the levels are maintained because they don’t always have to be completely absorbed. On the other hand, it means you need to have injections daily, which is not ideal because you do many injections during IVF.
It has better pharmacokinetics with the progesterone level. You can even do a combination of those two. Sometimes, we do use subcutaneous progesterone combined with vaginal one. They can get from two roots, and we don’t have any issues with just choosing one.
If there is an issue with the endometrium, the first thing would be to go with an estrogen cycle. Even with a frozen cycle, and hormonal replacement, the estrogen does not go more than 7 millimeters, this is a different case, and we can think about going back to the natural cycle. The first option, in our clinic and to my belief, is a cycle with hormones.
It’s not guaranteed, you could lose time. Hysteroscopy is a very straightforward day-case, actually, so sometimes, with high progesterone treatment, the polyps can go, but usually, it’s more difficult to go with treatments, and the easiest way to remove it is by doing hysteroscopy.
A healthy lifestyle, antioxidants, Vitamin E, C, reducing smoking and alcohol, it’s equally important for people with endometriosis. It has not been proven it can affect the chances of success significantly regarding diet.
We usually check it at the time of the trigger, at the time of the ovulation. In some cases, there is a point of checking after that to see what is happening if it is changing in pattern and things like that. Usually, we check it on the day of the trigger. On the day of the ovulation to see what’s the thickness size. This is the cut-off limit of more than 7, but ideally more than 9.