Endometrial Injury / “Scratch” / Implantation Cuts

Implantation success following in vitro fertilization (IVF) relays on several factors, including embryonic quality and endometrial receptivity. Repeated implantation failure (RIF) after IVF and embryo transfer (ET) is a frequent problem many patients struggle with. Two definitions of RIF are acceptable in the academic and clinical fields. The recent definition refers to RIF as failure to achieve a pregnancy after transferring at least four good‐quality embryos in a minimum of three cycles in a woman under the age of 40 years. This annotation differs from the former definition that described RIF as failure to achieve pregnancy following two to six IVF cycles, with at least ten good‐quality embryos transferred.

Endometrial injury (EI) was first described as a beneficial procedure for women with RIF during IVF treatments by Barash et al. in 2003. In this procedure, also known as endometrial scratching, the endometrium is locally intentionally damaged, usually by a Pipelle catheter. The underlying mechanism, through which endometrial injury improves implantation, is still not completely clear. There are three main supposed theories. First is through inducing decidualization of endometrium, which might improve the transferred embryos implantation. Second is that the process of healing after endometrial injury involves an inflammatory reaction mediated with cytokines, interleukins, growth factors, macrophages and dendritic cells, which are beneficial to embryo implantation. The third is that endometrial injury in previous cycle leads to better synchronicity between endometrium and transferred embryos through retarding endometrial maturation.

Many studies have been published on the efficacy of EI and its true benefit on reproductive outcome, including several reviews and meta‐analyses, and basic science studies. Improved clinical pregnancy rates (CPR) and live birth rates (LBR) have been apparent mainly in younger patients, while other studies have suggested improved reproductive outcomes in women with two or more previous failed cycles, with the greatest beneficial effect seen when double luteal EI was performed. Whilst globally accepted as a technique that can possibly improve implantation rates in selected patients, it still remains debatable the optimal timing of the procedure and whether it takes more than one EI to induce a proper immunological response.

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Dr Eleftherios Meridis