Endometrial scratching: how much evidence do you need to stop offering this to women having in vitro fertilization?

Moral justification for the use of 'add-ons' in assisted reproductive technology: experts' views and experiences

RESEARCH QUESTION

What factors do assisted reproductive terchnology (ART) providers take into account when they make decisions about offering 'add-ons'?

DESIGN

A qualitative analysis of interviews with 31 ART professionals, focusing on their views and experiences in relation to add-ons, including the factors that are considered when doctors make decisions about their use.

RESULTS

The participants reported that a range of considerations are taken into account when it comes to justifying the use of a particular add-on in a given circumstance, including the likelihood of benefit and harm, patients' perceived psychological needs and preferences, and organizational expectations. Importantly, patient preferences, psychological factors and low risk of harm appear to be stronger motivations than increasing the likelihood of a live birth or the desire to innovate.

CONCLUSIONS

These findings suggest that it cannot be taken for granted that add-ons and innovation are closely linked. One possible response to this would be regulatory reform; for example, only allowing 'unproven' add-ons to be used in the context of formal scientific evaluation. Alternatively, it could be made clear that add-ons that are not undergoing formal evaluation have more in common with other therapies lacking a clear evidence base, such as complementary and alternative medicines, than with conventional medical practice. Practices in relation to add-ons may also require a focus on the responsibilities of corporations, and the standards applying to purveyors of consumer goods and services.

Endometrial biopsy performed before the first in vitro fertilization does not impact the early pregnancy rate

Endometrial biopsy (EB) has been showed to increase the rate of clinical pregnancy in patients who underwent in vitro fertilization (IVF) failures. The purpose of this work was to assess the impact of an EB performed before the first in IVF on the early pregnancy rate. Be One study is a prospective, single-centre, randomized, open-label study. In this parallel study, patients were evenly split into two groups. In one group, patients underwent an EB between days 17 and 22 of the menstrual cycle that precedes the ovarian stimulation. In the other group (control), no EB was performed. The hCG-positive rate (early pregnancy rate) was evaluated on day 14 after the ovarian puncture. In total, 157 patients were randomized in the EB group and 154 patients were in the control group. The early pregnancy rate was 33.1% (52/157) in the EB group and 29.9% (46/154) in the control group (p = 0.54). Other parameters, including perforation, endometritis, or pain level were reassuring. An EB performed during the luteal phase of the menstrual cycle preceding the stimulation of the first IVF did not increase early pregnancy rate.

The impact of endometrial scratch performed in mid-luteal phase on the endometrium whole genome transcriptomic profiles in following menstrual cycle

The value of endometrial scratch in women with recurrent embryo transfer has been controversial. Endometrial scratch is often performed in the mid-luteal phase of the cycle preceding embryo transfer but there is little scientific evidence if it affects the whole genome transcriptomic profile of peri-implantation endometrium in the following cycle. A prospective longitudinal cohort study was conducted in a university assisted reproductive unit. A total of eight women with recurrent implantation failure (RIF) were included. Each participant had endometrial biopsy twice, first biopsy on day LH + 7 in natural cycle and second on day LH + 7 of the following cycle. R package was used to identify differentially expressed genes between the sample and enriched gene ontology. However, the paired sample showed no significant difference, neither known endometrial receptive gene set nor other genes, before and after the endometrial scratch. It suggests that endometrial scratch performed during previous mid-luteal phase did not affect the transcriptomic profiles of endometrium on day LH + 7 in women with RIF.

Subtle changes in perivascular endometrial mesenchymal stem cells after local endometrial injury in recurrent implantation failure

Improvements in reproductive techniques have resulted in the live birth rates from IVF procedures increasing from 5% to approximately 30% in recent decades but has plateaued since. Emerging preclinical and clinical data implicates endometrial receptivity deficiencies in patients with recurrent implantation failure (RIF) as the predominant factor hindering successful implantation. Mechanisms on how local endometrial injury (LEI) improves implantation rates in patients with RIF are currently unknown. We hypothesized that LEI may influence perivascular endometrial mesenchymal stem/progenitor cells (eMSCs) which are thought to regenerate the stromal vascular component of the functional layer every month. Here, we assessed the effect of LEI on the proportion and function of eMSCs present in consecutive LEI biopsies. Consecutive paired mid-luteal phase endometrial biopsies obtained from patients with RIF were digested to single cells and the proportion of SUSD2-expressing cells determined. Growth kinetics and decidualization were compared between the consecutive LEI samples. A mid-luteal LEI altered the decidualization capacity of SUSD2⁺ eMSCs in women with RIF, but not their proportion or clonogenicity. With the potential of LEI to improve IVF outcomes in women with RIF, additional investigations are needed to understand the impact of the altered decidualization response in eMSCs.

Impact of endometrial scratching on reproductive outcome in patients: A systematic review and meta-analysis

BACKGROUND

Endometrial scratching (ES) has demonstrated initial success in women with recurrent implantation failure, but the effect in women with 1 previous assisted reproductive technology (ART) failure is unknown. This meta-analysis aimed to evaluate the impact of ES as a treatment in clinical outcomes for women with at least 1 failed in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI)/Intrauterine Insemination (IUI).

METHODS

PubMed, Medline, Embase, Cochrane Library, Web of Science, CNKI, and EMCC databases were searched for randomized controlled trial studies utilizing endometrial scratching for infertility women with at least 1 failed assisted reproductive technology (ART) to collect pregnancy outcomes, including clinical pregnancy rate (CPR), embryo implantation rate (IR), miscarriage rate (MR), live birth rate (LBR), and multiple pregnancy rate (MPR).

RESULTS

Sixteen randomized controlled trial (RCT) studies were included in this meta-analysis, including 1770 women in the intervention group and 1934 women in the control group. Overall, the CPR, IR and LBR were significantly higher in the intervention group than in the control group (for CPR, n = 1430, 16 studies, P = .0002, risk ratio (RR) = 1.59, 95% confidence interval [CI] [1.24, 2.03]; for IR, n = 859, 10 studies, P = .0003, RR = 1.67, 95% CI [1.26, 2.21]; for LBR, n = 156, 6 studies, P = .0005, RR = 1.59, 95% CI [1.22, 2.06]). Nonetheless, there was no significant difference in MR (n = 344, 11 studies, P = .62, risk ratio (RR) = 0.92, 95% confidence interval [CI] [0.66, 1.29]) and MPR (n = 98, 3 studies, P = .39, risk ratio (RR) = 0.81, 95% confidence interval [CI] [0.51, 1.30]) between the intervention group and the control group.

CONCLUSION

Endometrial scratching is considered to enhance the reproductive outcomes of embryo implantation. Additional randomized controlled studies are recommended to identify the appropriate time of invasion and the applicable population to confirm whether it can become a routine operation.

Cumulative live birth rates in egg donor IVF cycles with or without endometrial scratching: is there a residual effect in subsequent embryo transfers? Follow-up results of a RCT in clinical practice

INTRODUCTION

Endometrial scratching (ES) is a simple technique that has been claimed to improve pregnancy rates in patients undergoing assisted reproduction techniques. Our objective was to acknowledge the effects of ES in subsequent embryo transfers by assessing the cumulative live birth rates (LBR) in patients undergoing egg-donor in vitro fertilization (IVF).

MATERIAL AND METHODS

We performed a follow-up analysis of the cumulative reproductive outcomes of the 352 patients included in the Endoscratch Trial (NCT03108157) during the twelve months following the randomization date. We compared the outcomes of patients who underwent an ES for the second and/or successive embryo transfers versus those who did not have an ES performed, in order to determine a possible carry over effect that could lead to different LBR in these groups.

RESULTS

Our analysis reveals that both groups (with and without ES performed before the first embryo transfer) had similar cumulative LBR (69.9% vs 65.9% in group A and B respectively, RR: 1.20, 95% confidence interval (CI): 0.92 - 1.22, p= 0.42). When we analyzed the results comparing patients who had received at least an ES before any of the embryo transfers during that period, we did not find any differences in LBR either (68.0% in patients with at least an ES and 67.8% in patients without ES, RR 1.00, 95%CI 0.87 - 1.16, p= 0.96).

CONCLUSION

According to our results, we cannot state that ES has a long term effect on endometrial receptivity of egg recipients as cumulative LBR do not differ from those of patients who do not receive it.

Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial)

STUDY QUESTION

Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period?

SUMMARY ANSWER

The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution.

WHAT IS KNOWN ALREADY

Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth.

STUDY DESIGN, SIZE, DURATION

This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK).

MAIN RESULTS AND THE ROLE OF CHANCE

More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth.

LIMITATIONS, REASONS FOR CAUTION

There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL5193/NTR 5342).

Experiences of trial participants and site staff of participating in and running a large randomised trial within fertility (the endometrial scratch trial): a qualitative interview study

OBJECTIVES

To explore the experiences of endometrial scratch (ES) trial participants and site staff of trial recruitment and participation, in order to improve the experience of participants in future trials.

DESIGN

Qualitative study of a subset of participants in the ES randomised controlled trial and a subset of trial site staff.

SETTING

A purposeful sample of 9 of the 16 UK Fertility Units that participated in the trial.

PARTICIPANTS

A purposeful sample of 27 trial participants and 7 site staff.

RESULTS

Participants were largely happy with the recruitment practices, however, some were overwhelmed with the amount of information received. Interviewees had positive preconceptions regarding the possible effect of the ES on the outcome of their in vitro fertilisation (IVF) cycle, which often originated from their own internet research and seemed to be exacerbated by how site staff described the intervention. Some participants appeared to not understand that receiving the ES could potentially reduce their chances of a successful IVF outcome. Those randomised to the control arm discussed feeling discontent; site staff developed mechanisms of dealing with this.

CONCLUSIONS

A lack of equipoise in both study participants and the recruiting site staff led to trial participants having positive preconceptions of the potential impact of the ES on their upcoming IVF cycle. Trial participants may not have understood the potential harms of participating in a randomised trial. The trial information sheet did not clearly state this; further research should assess how such information should be presented to potential participants, to proportionately present the level of risk, but to not unduly discourage participation. The amount of information fertility patients require about a research study should also be investigated, in order to avoid participants feeling overwhelmed by the amount of information they receive prior to starting IVF.

TRIAL REGISTRATION NUMBER

ISRCTN23800982.

Endometrial scratching in women with one failed IVF/ICSI cycle-outcomes of a randomised controlled trial (SCRaTCH)

STUDY QUESTION

Does endometrial scratching in women with one failed IVF/ICSI treatment affect the chance of a live birth of the subsequent fresh IVF/ICSI cycle?

SUMMARY ANSWER

In this study, 4.6% more live births were observed in the scratch group, with a likely certainty range between −0.7% and +9.9%.

WHAT IS KNOWN ALREADY

Since the first suggestion that endometrial scratching might improve embryo implantation during IVF/ICSI, many clinical trials have been conducted. However, due to limitations in sample size and study quality, it remains unclear whether endometrial scratching improves IVF/ICSI outcomes.

STUDY DESIGN, SIZE, DURATION

The SCRaTCH trial was a non-blinded randomised controlled trial in women with one unsuccessful IVF/ICSI cycle and assessed whether a single endometrial scratch using an endometrial biopsy catheter would lead to a higher live birth rate after the subsequent IVF/ICSI treatment compared to no scratch. The study took place in 8 academic and 24 general hospitals. Participants were randomised between January 2016 and July 2018 by a web-based randomisation programme. Secondary outcomes included cumulative 12-month ongoing pregnancy leading to live birth rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with one previous failed IVF/ICSI treatment and planning a second fresh IVF/ICSI treatment were eligible. In total, 933 participants out of 1065 eligibles were included (participation rate 88%).

MAIN RESULTS AND THE ROLE OF CHANCE

After the fresh transfer, 4.6% more live births were observed in the scratch compared to control group (110/465 versus 88/461, respectively, risk ratio (RR) 1.24 [95% CI 0.96–1.59]). These data are consistent with a true difference of between −0.7% and +9.9% (95% CI), indicating that while the largest proportion of the 95% CI is positive, scratching could have no or even a small negative effect. Biochemical pregnancy loss and miscarriage rate did not differ between the two groups: in the scratch group 27/153 biochemical pregnancy losses and 14/126 miscarriages occurred, while this was 19/130 and 17/111 for the control group (RR 1.21 (95% CI 0.71–2.07) and RR 0.73 (95% CI 0.38–1.40), respectively). After 12 months of follow-up, 5.1% more live births were observed in the scratch group (202/467 versus 178/466), of which the true difference most likely lies between −1.2% and +11.4% (95% CI).

LIMITATIONS, REASONS FOR CAUTION

This study was not blinded. Knowledge of allocation may have been an incentive for participants allocated to the scratch group to continue treatment in situations where they may otherwise have cancelled or stopped. In addition, this study was powered to detect a difference in live birth rate of 9%.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study are an incentive for further assessment of the efficacy and clinical implications of endometrial scratching. If a true effect exists, it may be smaller than previously anticipated or may be limited to specific groups of women undergoing IVF/ICSI. Studying this will require larger sample sizes, which will be provided by the ongoing international individual participant data-analysis (PROSPERO CRD42017079120). At present, endometrial scratching should not be performed outside of clinical trials.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by ZonMW, the Dutch organisation for funding healthcare research. J.S.E. Laven reports grants and personal fees from AnshLabs (Webster, Tx, USA), Ferring (Hoofddorp, The Netherlands) and Ministry of Health (CIBG, The Hague, The Netherlands) outside the submitted work. A.E.P. Cantineau reports ‘other’ from Ferring BV, personal fees from Up to date Hyperthecosis, ‘other’ from Theramex BV, outside the submitted work. E.R. Groenewoud reports grants from Titus Health Care during the conduct of the study. A.M. van Heusden reports personal fees from Merck Serono, personal fees from Ferring, personal fees from Goodlife, outside the submitted work. F.J.M. Broekmans reports personal fees as Member of the external advisory board for Ferring BV, The Netherlands, personal fees as Member of the external advisory board for Merck Serono, The Netherlands, personal fees as Member of the external advisory for Gedeon Richter, Belgium, personal fees from Educational activities for Ferring BV, The Netherlands, grants from Research support grant Merck Serono, grants from Research support grant Ferring, personal fees from Advisory and consultancy work Roche, outside the submitted work. C.B. Lambalk reports grants from Ferring, grants from Merck, grants from Guerbet, outside the submitted work.

TRIAL REGISTRATION NUMBER

Registered in the Netherlands Trial Register (NL5193/NTR 5342).

TRIAL REGISTRATION DATE

31 July 2015.

DATE OF FIRST PATIENT’S ENROLMENT

26 January 2016.

Endometrial scratching for poor responders based on the Bologna criteria in ICSI fresh embryo transfer cycles: a preliminary retrospective cohort study

Objective

This study evaluated the effect of endometrial injury on pregnancy outcomes in patients with a poor ovarian response (POR), based on the Bologna criteria, who underwent intracytoplasmic sperm injection (ICSI) cycles.

Material and Methods

Sixty-eight patients were enrolled in this retrospective cohort study. All patients in the endometrial scratching group (group 1, n=32) and control group (group 2, n=36) underwent office hysteroscopy in the early follicular phase of the cycle before controlled ovarian stimulation. Group 1 also underwent endometrial scratching. The main outcome measure was the ongoing pregnancy rate.

Results

The study groups had similar baseline demographics, including age, body mass index, duration of infertility, number of ICSI cycles, and hormone levels. However, the antral follicle count was significantly higher in group 1 than in group 2 (4.2±1.9 vs 3.3±1.8; p<0.05). There were no significant group differences in ovarian stimulation characteristics (ovarian stimulation time, trigger day endometrial thickness, number of metaphase II oocytes), number of embryos transferred, or the ratio of embryo transfer on days 3 and 5. Moreover, there were no significant differences between groups 1 and 2 in the rates of chemical pregnancy (25% vs 19.4%), clinical pregnancy (15.6% vs 11.1%) or ongoing pregnancy (9.4% vs 8.3%) (p>0.05 for all).

Conclusion

Endometrial scratching did not improve pregnancy outcomes for patients meeting the Bologna criteria for a POR to ICSI cycles using fresh embryo transfer and the GnRH antagonist protocol.

Platelet-rich plasma another add-on treatment getting out of hand? How can clinicians preserve the best interest of their patients?

Add-on treatments in IVF are utilized to a great extent but without sufficient evidence showing their effectiveness. Since the offered treatments are usually costly and may be associated with yet unknown risks, this practice is not in the best interest of couples that may go to great lengths to conceive and have an offspring carrying their own genetic make-up. A recent addition to this armamentarium is the administration of platelet-rich plasma (PRP) in women with diminished ovarian reserve, implantation failures, and a thin endometrium. The only evidence for PRP comes from small scale and mostly before and after studies with clinically irrelevant end points. PRP has not been subjected to a rigorous clinical trial. It is a typical example of an add-on gaining widespread popularity based on biological plausibility and mind-bending theoretical presumptions. We should be extremely cautious prior to implementing PRP on a widescale and await the results of well-designed studies.

Endometrial hyperplasia in infertile women undergoing IVF/ICSI: A retrospective cross-sectional study

OBJECTIVE

To describe the frequency and risk factors of endometrial hyperplasia (EH) in infertile women undergoing their first IVF/ICSI treatment.

METHODS

A total of 3198 infertile women undergoing their first IVF/ICSI cycle were recruited retrospectively from a fertility treatment center. Endometrial scratching and biopsy were conducted before IVF/ICSI treatment. The relationship between EH and clinical characteristics were analyzed.

RESULTS

EH without atypia, atypical hyperplasia, and endometrial cancer (EC) were diagnosed in 94 (2.94%), three (0.093%), and two (0.063%) women, respectively. The frequencies of EH were higher in patients with abnormal uterine bleeding (i.e. menstrual cycle irregularity in terms of frequency, volume, or length; 6.8% vs. 1.6%, P < 0.001, OR = 4.42), obesity (4.1% vs. 2.7%, P = 0.044, OR = 1.55), and elevated fasting glucose (4.6% vs. 2.5%, P = 0.017, OR = 1.85). In the multivariate analyses, all the three factors (abnormal uterine bleeding, obesity, elevated fasting glucose) were independently associated with risk of EH. In the subgroup analysis, among women with abnormal uterine bleeding, the frequency of EH in the elevated fasting glucose group was 10.7%, which was higher than that of the normal fasting glucose group (5.6%), even after adjustment for BMI (P = 0.014, OR = 1.53).

CONCLUSION

The frequency of EH in infertile women undergoing their first IVF/ICSI treatment was approximately 3%. Elevated fasting glucose was an independent risk factor for EH in infertile women undergoing IVF/ICSI.