Womb scratching

Dear Professor Winston

My husband and I have been trying to conceive for 5 1/2 yrs and have completed 3 fresh and 1 frozen embryo transfers. The first attempt resulted in a pregnancy which miscarried at roughly week 7. The further 3 attempts resulted in negative pregnancy tests. I have had a hysteroscopy and laparoscopy both I was told were clear of any problems. My husband has a low sperm count with a diagnosis of oligospermia and recommendation of ICSI which we have done on all 4 attempts. A report of my womb area from August 2011 showed an anteverted small uterus with an arcuate shape appears normal in echo texture and measures 66x42x28mm. The endometrium appears regular in outline and texture and measures 4.2mm, type D. Both ovaries are accessible. The right ovary is normal in size measure 26x25x17mm =5.9ccs and contained a 10mm follicle and 5 natural follicles. The left ovary is small, measure 23x21x17mm =4.3 ccs and contained 4 natural follicles. No obvious ad exam cysts, masses or pelvic free fluid seen. This is concluded as : small uterus and left ovary. After the 3rd attempt, I had a cervix stretch and mock ET as I had difficulty and pain with the implantation. I have the result pages for my husbands sperm analysis but there are so many numbers I really wouldnt know where to start. My question is this after 4 non pregnancy cycles the NHS have stopped funding us. In order for us to try again we will need to pay for it. We are looking around £7000 for this depending on where we go and what services we opt for. In your professional opinion, and I understand its difficult with having never met, would you advise us to give up? Or is there still a chance for us with private care? I’ve heard about embryo glue and womb scratching, this is not something we were offered on the NHS and it does sound wonderful but maybe we are being convinced about this method in an attempt to get us to spend more money with them. Any help you can suggest would be incredibly valuable. Many thanks K.

Dear K,

Sadly, nothing in IVF treatment is quite as wonderful as it may sound. The idea of causing a minor injury to the uterine lining came from some good scientists working at Weizmann Institute in Israel and they tried the idea out successfully afterwards in the local hospital in Rehovot. They found that this did improve the chances of implantation in the cycle immediately after the injury, and just possibly in the one after that. There are theoretical reasons why it may improve chances a bit but it doesn’t make a ‘wonderful’ massive difference. As for ‘glue’, the embryo does not need glue to attach itself to the uterus and it is highly probable that attachment is due to the embryo and its function rather than anything in the uterine cavity. Any ‘glue’ is likely to be a complex genetic message sent by a normal embryo to the uterus – that is to say, it is possible that a viable embryo is in control of its own implantation. So added substances are a very simplistic and unlikely solution. Incidentally, I greatly approve of the mock ET you had; this is a really useful way for the doctors on the unit to get some feel for how your uterine cavity is. Did they use ultrasound, too, during the transfer to ensure the catheter was in the right place?

As it turns out, many embryo transfer do themselves turn into a minor injury to the lining but it isn’t absolutely clear whether this is beneficial although there have been a surprising number of reports of people getting spontaneously pregnant soon after a failed IVF cycle.

One thing that occurs to me from your email is the finding of an ‘arcuate’ uterus which is reported as ‘small’. Was this done merely on ultrasound? Or was it diagnosed at hysteroscopy? Occasionally the finding of an ‘arcuate’ uterus can be significant and I always used ensure that a hysterosalpingogram was done in such circumstances with a tiny amount of die placed in the uterus. If there really is a marked change in contour, this argues a congenital abnormality which just may be significant and can be corrected before another IVF cycle.

An answer to those questions might be helpful, and an HSG useful if you haven’t had one – it’s a lot cheaper than a failed IVF cycle.

Best wishes
Robert Winston