Endometrial receptivity, endometrial scratch, and implantation window – how and when they influence IVF success

Inna Moroz, MD
Fertility Specialist at ISIDA, ISIDA Clinic
Svetlana Shiyanova, MD
Chief Doctor at ISIDA, ISIDA Clinic

Category:
Embryo Implantation, Embryo Transfer, Success Rates

From this video you will find out:

Endometrial receptivity, endometrial scratch, and implantation window – how and when they influence IVF success

Endometrial scratch vs implantation window and IVF success rates

Any subject stops being difficult when it is presented in a clear and comprehensible way. In this webinar, two fertility experts from ISIDA IVF: Svetlana Shiyanova (Chief Doctor from the Infertility Treatment Center) and Inna Moroz (Fertility Specialist) accepted the challenge and explain step by step some of the most complicated issues of IVF treatment processes: endometrial receptivity, endometrial scratching and implantation window. All in all we think they did an excellent job!

What is endometrial receptivity?

Inna started with presenting the four stages of embryo implantation: orientation, apposition, attachment and invasion. She explained that the endometrium, the inner lining of the uterus, has to be in a perfect condition for the embryo to successfully complete all the implantation stages and begin developing into a fetus. However, the condition of the endometrium is not always ideal for embryo implantation and this can be the cause of Recurring Implantation Failures (RIF). Obviously, the quality of the embryo is key. Even if the endometrium is in perfect condition, the attachment and invasion stages will not take place if the embryo quality is low (when it has genetic abnormalities for instance). Only the successful interaction between these two guarantees the best outcome of the implantation process. According to Inna, evaluating the condition of the endometrium before the embryo transfer is very important. Hormones such as estrogens and progesterone stimulate growth and development of the endometrium during a woman’s menstrual cycle. Changes in hormone levels affect the endometrium thickness and the number of glands and vessels on the surface of the uterus wall. This in result impacts the receptivity of endometrium during implementation stages. If the thickness of endometrium is less than 7 mm, it is not in a good condition to accept the embryo. Only when it reaches 8 mm and more, can the doctors proceed with next stages of implantation process.

Endometrium evaluation

nna highlights that the endometrium has a very difficult constitution and it has to be evaluated with different markers and factors such as immune cells, signalling factors, nutrients and physical environment. It all can be helpful in determining any form of potential endometritis. The endometrial evaluation can also be based on gene expression analysis – this is another way of checking if the endometrium is ready to accept an embryo of great quality.

What is the window of implantation?

Inna explains that the window of implantation is the time when a woman’s endometrium is most receptive and ready to accept your embryo. If you have the regular cycle of 28 days with a possible ovulation around the 14th day, the best day for embryo transfer will be from 19th to 21st day of the cycle. There are a lot of genes to be expressed at different stages of the menstrual cycle. As the window of implantation can be displaced, it is necessary to conduct the analysis of endometrial receptivity genes. By using the real time PCR method, more than 400 genes that can be expressed and evaluated. Inna says that in order to determine the correct window of implantation for a patient, they need the so-called ‘REpoint’ test for endometrium receptiveness genes.

How to evaluate the result of the ‘REpoint’ test?

According to Inna, the results of the ‘REpoint’ test can be very useful in creating an individual treatment plan for a patient. If the test determines that the endometrium is pre-receptive, it means that the embryo transfer has to be postponed for a couple of days. It is also necessary to increase the number of days of progesterone supplementation. If the test shows a receptive result, it means it is the right day for the implantation and embryo transfer. Consequently, if there is a post-receptive endometrium result, the embryo transfer has to happen a little bit earlier and the number of progesterone supplementation days has to be cut down.

Why is it important to use the ‘REpoint’ test?

Inna and Svetlana highlight that up to 25% of population has a displaced window of implementation. Identifying the ideal window requires the analysis of the endometrial receptivity genes. Without the proper testing, it is easy to decrease the chances for successful embryo implantation. Inna and Svetlana also present three most important cases when REpoint test is used in their clinic. These are the following:

RPF (recurring pregnancy failures)
Embryo transfer after pre-implantation genetic testing
Suspecting a change in the implantation window after miscarriage

Endometrial scratching

The last subject Inna and Svetlana dealt with during their webinar presentation was a technique called endometrial scratching. A biopsy is applied to the endometrium to create an injury or tissue irritation. According to Inna, this technique should lead to the process of tissue regeneration and, as a result, to the improvement of endometrial receptivity. Although there is no conclusive research which proves the effectiveness of endometrial scratching the technique is used when the doctors suspect that there are some immunological factors behind the woman’s infertility. Of course any decision has to be proceeded by a careful and detailed evaluation of a patient’s individual case and her endometrium immunological issues.

Endometrial scratch vs implantation window and IVF success rates - Questions and Answers

How long is the result of the endometrium receptivity map valid? For how many cycles after the test has been done?

These results are valid for the long period of time. So if you’re planning your IVF treatment or if you have recurrent pregnancy loses for an extended period of time, you can use this method just once. The biopsy is fairly informative for the next cycles in the following years, of course if there are no changes in your health, etc. Even if you have had delivery or Caesarean section, it doesn’t change after few years. This is a very exact analysis measured by genetic testing.

Is it easier to prepare a woman for the transfer in IVF programmes with donor eggs? If yes, could you explain why?

The preparation for the IVF programme with donor eggs doesn’t change with the regular endometrium preparation. It depends if you use the fresh cycle of the donor or cryo-cycle or cryo-oocytes. If you use the cry-oocytes, we use the same preparation: long or short protocol , depending on your situation. We do not need the extra synchronisation with the donor. But if you use the donor’s fresh cycle then it’s a little bit complicated. We need to synchronise the donor’s and your cycle and it takes longer time, up to 1 or 2 months. It depends on your situation and the day of the donor’s cycle. We do most of the cycles with vitrified donor’s oocytes as it is easier to prepare a patient. The method of preparation depends on whether the patient has ovulation or not. If a woman is younger and she has ovulation, it can be in your own natural cycle. However, it’s a rare case. In majority of cases it’s a method with HRT therapy, medications containing female hormones your ovaries stopped to produce.

What can cause the change of the endometrium receptivity?

As we explained before, there are different changes. Sometimes we can find e.g. immunological factors or chronic endometriosis by biopsy. We can exclude them and try to put the good embryo that was genetically tested before. But we cannot understand what happened after this. We can exclude all of these factors but it is still a little bit unclear how we can change receptivity. It also depends on the stage of the disease you might have at the same time, like endometriosis or adenomyosis. Different changes in your hormonal status can change endometrial receptivity. It’s been also shown that simple vitamin D increases the receptivity for endometrium. So we may try to identify different factors but it all doesn’t guarantee that after that we have 100% chance of a receptive endometrium. That’s why we use the REpoint method and try to see the window of implementation, the best time for you to accept the embryo. The research shows that sometimes there are only 12 hours (and not 24 hours as usual) for the embryo acceptance. So we have to be very precise and very strict regarding this day. And we have to exclude all the factors that can influence before that. Before the IVF cycle, it is important to be investigated for other gynaecological diseases. It is also crucial to test the embryo for possible genetical abnormalities, as all of this can influence endometrial receptivity.

Are vitamin E 600, L’arginine 1000, Vit B complex, Zinc and Selenium advantageous for increasing endometrial thickness?

There are different supplements such as vitamin E, L’arginine, vitamin D, Zinc, Selenium, etc. that can somehow improve the receptivity or thickness of the endometrium. But there is no research to prove that. Especially in case of the thickness. As estrogens are responsible for the thickness of endometrium, first of all we have to make sure there is enough estrogen to increase the blood flow in the endometrium and as a result, improve its receptivity and thickness. In our usual practice we use vitamins and supplements only for a special category of patients. It depends on their previous cycle history, previous attempts and the level of these vitamins in their blood.

Are there any recommendations for nutrition and supplements to increase endometrium receptivity?

You should try to be on a healthy diet but we cannot suggest any particular vitamins and supplements that would be required during embryo transfer treatment. Only after the evaluation of those nutrients we can try to adjust the vitamins and supplements according to your situation. Of course we advise you to use vitamin E and folic acid as they are very important in the preparation for the pregnancy. Sometimes vitamin D and other supplements may be required in your particular case. Not everything is for everybody so we have to precisely analyse every patient to choose exactly what they need. Unfortunately we don’t have magic pills for improving endometrium thickness and receptivity.

What do you think about ERA test, do you believe it might be helpful in some cases? For example, when there is lack of the implantation despite good quality of embryos?

ERA test has been longer on the market so it is more popular. It has the same purpose as the REpoint test but the method of evaluating the expression of genes is different. In the REpoint test we use PCR method for exactly those genes that are required for implantation. ERA test, on the other hand, is very comprehensive, it is used for more than 200 genes. That’s why it is a little bit more expensive and is not usable for all the patients. In our REpoint test, we evaluate exactly 15 genes by a real-time PCR method so we just see the genes that are responsible for endometrial receptivity. And it is less expensive than the ERA test. Today ERA test is most commonly used as the method for identifying the exact time for embryo implantation.

Is endometrial scratching beneficial only in the following cycle or also in 2 or more cycles later? Answer:

Usually it is believed that we can use it only in one cycle before the embryo transfer. It is not beneficial to use it in other cycles. An extra injury to the endometrium would be needed to create the injury regeneration process and somehow improve the receptivity. It is a little injury and we’ll see its effect on the next cycle, but not after 2 or 3 cycles. The purpose of this method is to improve the blood flow in the endometrium and that’s why the effect of this injury is for maximum 2-4 weeks. Usually we use this endometrial scratching just before menstruation and after menstruation we prepare the endometrium for the embryo transfer. We don’t use this method for all the patients. We conduct special immunological test for uterus endometrium to prepare the immunological profile. We investigate uterus neutral killer cells and we prescribe scratching, depending on the nk cells activity. We have to be very careful and remember that it is an injury and it may be very harmful.

Does endometrial scratching cause injury or scar tissue formation? Will it cause endometriosis and adenomyosis?

No, endometrial scratching cannot create scars or big injuries . It’s like a ‘pepper’ biopsy that is used to check e.g. endometritis. We put a small tube into the endometrium, it is only for one cycle and it is followed by the regeneration of whole endometrium so don’t be afraid of any big injuries, endometriosis or adenomyosis. The latter are caused more by hormonal changes, and there’s no relation between endometrial scratching and hormonal changes in a patient. We don’t use this method very often. Only once or twice during the period of treatment, surely not more than twice. If we don’t have the results after maximum the second time, we don’t repeat or recommend this test as there is no beneficial effect.

Are there any statistics showing how endometrial scratching increases the chances of implantation?

No, at our clinic we do not have these statistics and even in the whole IVF world there is no such research. We only know that it can somehow improve the receptivity but we don’t have 100% beneficial effect of this method. That’s why it is not so popular. For last ten years there has been a lot of investigation among patients on this subject but we don’t have proof of the effectiveness of this method.

Can endometrial scratching help women with a thin endometrium before transfer?

As we discussed before, we cannot use this method for every woman. We use it only for those women who have immunological issues. There is a different method used for recurrent thin endometrium. There are different medications given that increase the thickness of endometrium. Only if we don’t have any results of medications, we can think of endometrium scratching to help this woman. If we have thin endometrium, we prescribe endometrial scratching just before the cycle when we make embryo transfer or in an early phase of your menstrual cycle. But it is not a main therapeutic method.

Is it necessary to wait after the REpoint test before transferring frozen embryos? For how long?

We need to wait for the results for maximum 4 weeks. If you have the frozen embryo it is not necessary to be in this stage, it has no influence. So we can do this test and after the results we can have the embryo transfer according to the results. If we plan to make a transfer in a cycle with HRT therapy, the analysis should be taken in the same cycle. In HRT therapy we prescribe estrogen pills for 10 days plus usually 6 days of progesteron, and after 6 days we take this analysis. It is aspiration biopsy from uterus. And after we have results, we prepare this woman in the same way for embryo transfer according to the results. If we plan to have embryo transfer in a natural cycle, we should estimate exactly the day of ovulation and count a special day for the analysis. But in majority cases unfortunately we don’t have own regular cycle.

Can you pleases explain more about the type of immunological factors that can affect implantation and after how many failed own egg cycles would you start to look into this?

Immunological profile of endometrium is a very rare analysis. Even if we don’t have results after 3 attempts with egg donation cycle, it is not the first analysis for investigation. It’s maybe last because the first is the quality of embryos. Embryo quality constitutes about 70% of chance for success. Our own endometrium is only about 30% of chance and it often depends on e.g. good thickness or good blood flow. If we make special investigation for the implantation window, ERA or REpoint test in our case, and we don’t have any results, the next step we make is the immunological profile of endometrium. It’s the same way as we take aspiration biopsy from endometrium and we precisely investigate the nature and number of natural killer cells. Depending on this result, we decide on special therapy. To be precise: when we have low level of natural killer cells, we prescribe scratching. Before the investigation of immunological factors, we need to exclude the endometritis . Sometimes the inflammation of the endometrium can create bad environment for natural killer cells. So make sure the doctor will exclude the endometritis and after excluding this, you have to check your natural killers to see if you need other investigation and methods to improve receptivity. It is very important as lot of patients have chronic endometritis. If you’re not planning IVF treatment or pregnancy, you cannot realise you have chronic endometritis of uterus as it is not seen in a regular Pap test or smear. Only through histochemical method you can see if there is inflammation presence and natural killer cells presence in your endometrium at the same time. And if you need to treat just one or both. Actually, we use it very regular in our IVF treatment and even before the frozen embryo transfer. When we investigate our patients, we can see that chronic endometritis is in close connection with a high level of uterus natural killer cells.

Which factors can influence the endometrium receptivity? What can cause the change of the implantation window?

Generally all the same factors we have been talking about earlier. Immunological, hormonal changes, the quality of embryo, all the factors we can see by regular instrumental methods. By ultrasound we can see only the thickness and how it grows but we cannot see what is inside. That’s why we can use an additional investigation and to see how it influences receptivity. All those factors can influence the chance of having the implantation window. But in general the window of implantation is a special thing for your organism and it depends on the expression of those genes that are supposed to be dependant on the hormones that your organism provides in the whole cycle. That’s why if you don’t have the regular ovulation and natural cycle, we create your cycle with HRT therapy. We can create exact days for estrogen, then proliferative phase and for the secretory phase. Because when we use the progesterone, we guarantee good thickness of endometrium. We can suggest that on the 5th or 6th day of supplementation we have the best receptive endometrium. About 80% of patients usually have the regular receptive window on the 5th day of the progesteron supplementation. But 12% of patients don’t have the receptive endometrium. That’s why it’s important especially if you have recurrent pregnancy failures or unsuccessful attempt to use this method right before the embryo transfer to have success with this cycle. If a patient doesn’t have her own regular cycle and regular menstruation, we should obligatory prescribe estrogen and then progesteron. And only after that we can make this analysis.

Do you perform endometrial scratching in a pill cycle (with contraceptive pill) before the FET cycle?

It can happen. When a patient takes contraceptive pills, her endometrium is very thin. Not more than 5 or 6 mm. When we make an injury just before menstruation, we can influence the next cycle and prepare the endometrium better.

Do you test the endometrial tissue (with biopsy) on natural killer cells and endometrium inflammation? In which cases? Which patients is it beneficial for?

We use this test very often. Especially with those patients for whom we only have 1 or 2 embryos and we don’t want to lose these embryos. We use this method before the embryo transfer cycle so we do this biopsy and we have the result for inflammation and at the same time for natural killer cells. So the result will be the same. If you have the inflammation or some changes in natural killer cells, you will be treated right before the embryo transfer. And after repeated negative results following inflammation treatment, we can proceed with embryo transfer. Sometimes it requires more than one cycle of the treatment. For example, when we have endometritis resistant to regular antibiotics, we have to change antibiotics to different ones. Sometimes we can use 2 different types of antibiotics during the same immunological therapy to improve the condition of the endometrium and to have negative inflammation result.

What are natural killer cells? How can I know what is my condition?

You can make aspiration biopsy and take some cells for immunological profile. But it is not obligatory for majority of patients. It is not a routine analysis. Usually we don’t need this test. When we have great quality of embryo, especially after NGS testing, without any genetic abnormalities, when we have great endometrium with right window of implantation, without any inflammation, then the chance for implantation and especially live births rate is around 60% for first attempt. If you don’t have success on first attempt, the second attempt will include some more investigation and analysis. Not even the analysis of natural killer cells, we have a lot of other additional types of investigation to see why it didn’t happen for the first time. And then, when we have 3 or more repeated failures, we can use this test to see if we need to change something in the immunological profile. Maybe we should add extra medicine or extra treatment to the embryo transfer cycle. We don’t prescribe this analysis earlier than after 2 negative attempts. Only when we have the high quality of embryos and 2 transfers without results, we can investigate natural killer cells of your uterus.

Is there a risk of impact of vitamins overdose?

Some of the vitamins have to be taken very carefully. For example, vitamin E in overdose can create bad environment for a future fetus, future embryo. If you use a higher dose of e.g. vitamin D, vitamin E or other supplements for more than 3 months, you have to check your profile with the doctor who prescribed you those vitamins. You should do it to see if you don’t have the overdose because then you’ll have the negative effect of your embryo transfer and the whole IVF treatment plan. We always change the dose of vitamins right away after the positive pregnancy test. We decrease the dose and adjust it to the pregnancy level. That’s why we need to be very careful and you need to follow the instructions of your doctor.

Is there any danger in endometrium scratching? What day should you perform it?

As we said, we can use endometrium scratching in only few cases and after the thorough investigation of the endometrium. And we can use it only on the cycle before the right cycle, exactly from 2nd to 5th day of a patient’s period. But not more than 1 or 2 times during the whole process of the preparation for embryo transfer. It is recommended to make this procedure just before menstruation. And in the next cycle we should prepare the endometrium for the embryo transfer. We sometimes change this procedure and make the scratching in earlier follicular phase. We don’t have strict indications for scratching in the exact period of time, unlike with the implantation window.

Do you treat endometrial inflammation with doxycyclinum?

Yes, we start with doxycyclinum for the first time. More than 70% of patients will respond to this therapy. But around 20% of patients will not respond to this medication and then we will have to change to another medication according to the case. The first line of therapy is doxycyclinum. If the patient had doxycyclinum before, we prescribe another medication, a macrolide antibiotic. If after that we make a control test and we have a repeated result, we make special test for sensitivity to antibiotics. But it is not a general sensitivity test from the blood flow. We take a special sample from inside the uterus for bacteriological investigations to see how sensitive to antibiotics the endometrium is. So we always start with a regular antibiotic and after repeated positive results, we will have antibiotic sensitivity testing .

My progesteron level is always too low on the transfer day or the day before ( 8 or 24 Nml). Does it mean that my endometrium is not receptive or it has nothing to do with receptivity? My 4 attempts failed and I just wonder if it could be because of lower progesteron. Can Hashimoto disease influence the receptivity? I don’t have endometritis.The doctors measured the progesteron in blood. My endometrium is always 10 mm.

If you excluded endometritis and you have Hashimoto disease, then yes. If your TSH level is high, it needs to be corrected. High level of antibodies created during this disease can influence the receptivity. It is important where we measure the progesterone. It is very important to make biopsy from uterus and a special test for receptor of progesterone. And only endometrium receptor of progesterone can explain the insufficiency of second phase. We can use the same biopsy to see if you have chronic endometritis, natural killer cells and progesterone and estrogen levels. So we can have one biopsy and see all of the results. Only after that result, we can exactly tell you if low progesterone is the reason for failed attempt. If this result shows you have insufficient level of progesterone, you can add additional progesterone in a different form, e.g. intramuscular injection or extra vaginal suppositories test. From regular analysis we cannot tell you exactly if it is your case or if it’s not.

How can i know if I have chronic endometriosis? What is the test for that?

We have to differentiate between endometritis and endometriosis. Endometritis is the inflammation we were talking about. So we have the biopsy from the endometrium at the exact time and then we can see if we have endometritis and if we need antibacterial treatment or not. Endometriosis refers to hormonal changes. If with the use of ultrasound we indentify, for example, adenomyosis or different condition on your tubes, at this time we can suspect endometriosis. Usually if there is endometriosis, patients complain about pain, especially during the intercourse or menstruation. The only precise diagnostic test in this case is hysteroscopy or laparoscopy. It allows to see exactly the lesions on the uterus or ovaries. Then we take biopsy from the lesions and investigate it exactly from histological point of view. Endometriosis is a disease in which similar to endometrium cells are found in other places in the body, e.g. on the uterus, tubes or ovaries. It is a very bad condition for implantation as it can lower the receptivity of the endometrium, even if all the other conditions, like endometritis, are excluded.

Do you use Tacrolimus (to lower the immune system) in your treatment?

Tacrolimus is a very serious medicine and we don’t use it to lower the immune system. We have to carefully dose all medications. Sometimes they can be harmful to a patient and the whole procedure. If we don’t have the academic research that can prove the effectiveness of a particular method, we don’t use it in our treatment and we don’t suggest to use it in a therapy. Before prescribing those strong immunological medicines, you should very carefully investigate your body, especially the condition of the immune system, to exclude the risk of oncology diseases. Using such medicine can sometimes improve our IVF treatment, but in other cases, especially when you have some susceptibility to cancer or autoimmune diseases, it can be very harmful to your health. That’s why we have to be very careful with that.

I have 6 failed cycles with good quality donor eggs and embryos. Do you think ERA test will help? I had 3 cycles with my own eggs and 2 with donor eggs. All of them failed. I had PGS in donor eggs. I do have endometriosis.

The main question is if you had the genetic testing of your embryos. We can add this test to improve the chances of getting pregnant. In majority of cases (about 85%), embryos with donor eggs have normal number of chromosomes. If you have more than 3 negative attempts, the next step is to investigate the window of implantation. Then investigate immunological profile of uterus. And then the endometriosis treatment is very important as it influences the receptivity of endometrium.

We have done the ERA test, the result is receptivity on day 6. How long is this result valid and what can change this result?

If you have the result so it means this is exactly the best day for embryo transfer. It doesn’t change, we know that there is no influence of other factors on this. You can be safe and do your embryo transfer on exactly that day. It can happen that although we know when you have your implantation window, there are other factors that can influence your chance of implantation. For example, you can have sickness of endometrium, meaning that endometrium is very thin, or you can have endometritis or endometriosis. The theme of this presentation is of course the implantation window, but you have to remember that there are other important factors that influence implantation and the success of your entire programme.

There are doctors that say that the endometrial receptivity test result is valid only in the cycle when the biopsy was done. Is it true? If not, why?

None of this is true. There is academic research that we can send to you that says the endometrial receptivity test result is valid all the time and it does not need to be repeated. One biopsy is enough to see if there is a receptor. The results of that research are open, you can find them online if you want to.

Can low blood pressure influence the endometrium and its receptivity? Does it have any influence on getting pregnant?

For now there is no research showing there is influence of low blood pressure on endometrium receptivity. So we cannot combine these factors. If you know that you’re pregnant, you usually have low blood pressure because of changes in the circulation, especially in the first trimester. So we can say for sure there is no influence of low blood pressure on receptivity of endometrium.

I did a natural killer cell test and it was ok. However, I had 2 chemical pregnancies and I was thinking about asking my doctor to add the immunological protocol as well as Medrol to my next transfer. Is it advisable?

We should know exactly what kind of natural killer cells were identified. It very often depends on their number and activity. Then we prescribe Medrol or other stimulating medicine, like IVIG. We should know exactly what is the level of natural killer cells. You have to be very precise if these are endometrium natural killer cells or blood natural killer cells. Blood natural killer cells investigation is not very informative as different conditions or diseases in your body can influence this test. But you have to check if the endometrial natural killer cells are your case or not. You have to know if you need to take immunoglobulin or Medrol for the next cycle to suppress or stimulate your immune system, depending of course on your profile.

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Authors

Inna Moroz, MD

Inna Moroz is a doctor of Medicine and Fertility Specialist with 12 years of professional experience. She's been part of the ISIDA team since 2018. She's a member of the international societies of the reproductive medicine such as ESHRE (Europe), ASRM (USA), CFAS (Canada), UMANA (USA), and the Ukrainian Association of Medical Doctors. Inna Moroz speaks English, Russian and Polish.

Svetlana Shiyanova, MD

Svetlana Shiyanova is a Chief Doctor of Infertility Treatment Center at ISIDA Clinic. Fertility specialist, obstetrician-gynaecologist with 16 years of professional experience. In 2013 Dr Shiyanova has completed training course relating to endoscopic treatment methods in gynaecology in France. Languages: English & Russian

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