The chronically thin endometrium has remained an unresolved clinical problem since the inception of IVF. It has been known for a very long time that best pregnancy rates are achieved when the endometrium reaches a thickness of 9mm on ultrasound measurement, but that 7mm really represents the minimum thickness for reasonable pregnancy chances.
There are, of course, other parameters that count as well: For example, how the endometrium looks also matters. Ideally, it should present not only with appropriate thickness but also nicely layered. Innumerable studies have been reported in the literature, and almost as many suggestions have been made on what can or should be done in case the endometrium does not meet expectations.
Here is the scenario as it presents itself over and over again in association with IVF at the Center for Human Reproduction (CHR): With the IVF cycle coming closer and closer to the day embryos have to be transferred, the patient's endometrium still does not meet minimum criteria for transfer.
What to do?
Most IVF centers follow standard treatment algorithms that sometimes work: We usually start by giving or increasing estrogen support; if that does not work, a vasodilator is added. At CHR, a clinic for IVF in New York, we usually utilize a beta-blocker, called Atenolol or, believe it or not, Viagra, as many colleagues do. When nothing works, however, the choices become stark: either the whole cycle is simply cancelled or the patients still go to egg retrieval, embryos are created, but not transferred into the uterus. That means patients have to go through an all-freeze cycle, where all embryos are cryopreserved. This is because it would be a total waste of good embryos to transfer embryos into an inadequate endometrium.
This year, CHR had a Chinese patient from out of state in a similar situation. Her situation was even worse, in fact, because in addition to very thin endometrium, she also had a fluid accumulation in her endometrial cavity. Seeing the dismal pregnancy chance with the condition of her endometrium, Dr. Norbert Gleicher, CHR's Medical Director, suggested she cancel the embryo transfer and freeze all embryos. However, she opted to go through embryo transfer, due to the time constraints involved in her long-distance care. She asked Dr. Gleicher if there was anything "experimental" that could be done.
Dr. Gleicher offered her aspiration of the fluid, and decided to treat her off label (with appropriate informed consent) with an FDA-approved drug with well known systemic effects, which he thought, theoretically, may have a chance to beneficially affect the endometrium.
Two days later, the patient demonstrated a perfect endometrium! She had egg retrieval, had a routine embryo transfer (after preimplantation genetic diagnosis, PGD) and is now pregnant with twins.
After two more patients (and one other at a nearby center) with dramatically improved endometrium after this experimental treatment, CHR decided to develop two prospectively randomized clinical trials to prove this hypothesis. If proven, being able to go from utterly insufficient endometrium to perfect endometrium with this medication will have a tremendous impact on IVF outcomes. Dr. David Barad, Clinical Director of IVF at CHR, is hopeful: "Preliminary results so far have been remarkable. This promises to be another clinical "hit" after DHEA treatment, produced by CHR research."
The Center For Human Reproduction in New York, NY specializes in infertility treatment, egg donation and research related to fertility. The CHR provides a low cost of IVF and discounted IVF costs for families with need. Their website is www.centerforhumanreprod.com
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