Advanced Techniques

What is Endometrial Scratching (ES)?

Endometrial scratching (also called endometrial biopsy) is a procedure that can increase the success rate of conception in women undergoing IVF-ICSI who have had multiple unsuccessful IVF cycles.

The endometrium is the layer of tissue on the inside of the womb. Implantation occurs when an embryo attaches to the endometrium. Endometrial scratching purposely disrupts the endometrium to increase the chance of an embryo implanting, resulting in a successful conception.

The procedure involves taking a biopsy of the lining of the uterus, called the ‘endometrium’, using a thin catheter (pipille) that is passed through the cervix.

Who is Endometrial Scratching suitable for?

Endometrial scratching is typically only performed if implantation has not occurred and the patient has not conceived after two or more previous IVF cycles, despite the transfer of good quality embryos.

It may also be offered before some frozen embryo transfer cycles but the evidence for its effectiveness in these cases is not as strong.

The procedure is generally reserved for the cases mentioned above as no benefit has been shown for other patient groups including women trying to conceive naturally, those undergoing IUI, first IVF cycles and first frozen embryo cycles and also women with a history of previous miscarriage.

How does Endometrial Scratching help implantation?

The procedure has been shown to improve the chance of pregnancy in some women. It is generally performed approximately 7 days before stimulation for an IVF cycle.

Research and evidence indicate that ES works by causing a ‘repair or wound healing reaction’ which may help the implantation of the embryo by triggering the release of immune cells, growth factors, hormones and chemicals. It’s thought that the new lining that grows after the procedure is more receptive to an implanting embryo and so increases the chances of implantation and of pregnancy.

Having an Endometrial Scratch

If there is any chance that you may be pregnant, the procedure cannot be performed. If you have intercourse at any time from the first day of your period you MUST use reliable protection.

How to prepare for an endometrial scratch

An ES is best performed approximately 7 days before the expected menstrual period on which your fresh IVF or ICSI cycle is about to start. For down regulation cycles this is usually also the day that you start your down regulation medications.

  • You may eat and drink normally before the procedure
  • It helps to have a comfortable full bladder
  • Mild pain relief (e.g. Nurofen) may be taken 40 minutes prior to ES
  • No sedation is required and the procedure is similar to that of an embryo transfer
How is the procedure performed?

The procedure is similar to an embryo transfer:

  • A speculum is gently inserted into the vagina so the cervix can be seen
  • The cervix is cleaned with sterile gauze
  • A thin flexible catheter is inserted through the opening of the cervix, and the uterine lining is gently ‘scratched’. (Inserting and moving the intrauterine catheter up and down may cause mild abdominal cramping similar to period pain).
After the procedure
  • You can go back to normal activity e.g. work, driving
  • You will need to wear a sanitary towel (not a tampon)
  • Some mild bleeding and cramping are common after the procedure
  • Other complications such as infection or perforation of the uterus are extremely rare.

If you experience any of the following symptoms within a few days of the ES, you should contact us immediately:

  • Unexplained fever
  • Persistent bleeding or foul-smelling vaginal discharge
  • Increasing lower abdominal pain
  • Feeling generally unwell

What is Surgical Sperm Retrieval (SSR)?

Surgical Sperm Retrieval refers to any method that is used to get sperm from the man for fertility purposes.

When is Surgical Sperm Retrieval recommended?

SSR is generally performed for men under the following circumstances:

  • little or no sperm in the ejaculated semen
  • failed vasectomy reversal
  • where there are problems with normal ejaculation (e.g. MS or Diabetes)
  • spinally injured men

What is involved in SSR?

When undergoing SSR, an Anaesthetist will provide sedatation & pain relief during the procedure.

The retrieved samples will be processed in the laboratory to find any functional sperm. The number of sperm is generally small and generally have reduced motility, so the best chance of fertilization with your partner’s eggs is though ICSI. The function sperm is then prepared and frozen for future use in an ICSI cycle.

The embryoscope is a highly specialised incubator a microscope, time-lapse camera and computer that offers a number of advantages over traditional incubators, including:

  • This combination of technology allows time-lapse imaging of embryos at very frequent intervals (every 15 to 20 minutes), whereas traditional incubators observe embryo development only one or two times a day.
  • The embryoscope involves is minimal handling of the embryos during the culture period as they remain undisturbed while the computer records the images.

The embryoscope provides a vast amount of additional information about each embryo. This can be more beneficial to some IVF / ICSI cases than others, depending on the number of embryos available.

The additional information can enable the selection of the embryos with the best potential for pregnancy where there are multiple embryos to choose from.

If there are only a limited number of embryos suitable for transfer, we do not generally recommend the embryoscope as it isn’t necessary to choose between the embryos.

Vitrification is a rapid freezing technique using liquid nitrogen to minimise the formation of ice crystals that could cause cell damage.

This technique has replaced the previous method of ‘slow freezing’ and survival rates of embryos have since improved from ~70% to >90%.

Cryopreservation is the process of freezing embryos, eggs or sperm to preserve them for use at a later time. This is done using the rapid freezing technique called vitrification.

Embryo cryopreservation allows multiple embryo transfers from a single egg collection and gives a better chance of pregnancy from a single surgical intervention.

Following Embryo Transfer, there may be surplus embryos that are of good quality that can then be frozen and thawed at a later date for use during a FET cycle (Frozen Embryo Transfer).

Embryos must be of good quality to endure the freezing and thawing process. so regrettably not all embryos are suitable for freezing. Approximately 50% of women undergoing IVF / ICSI will have additional adequate quality embryos available for freezing.

 

Oocyte vitrification or egg freezing is the process of collecting mature eggs or oocytes from a woman’s ovaries and rapidly freezing them to preserve them for future use.

In order to have a suitable number of eggs to collect, fertility drugs are used to stimulate the ovaries to produce multiple eggs. The developing follicles which contain the eggs are monitored by ultrasound scan, and when they are large enough, the eggs are removed from the ovary by a minor surgical procedure.

The eggs are rapidly frozen by vitrification to prevent trauma to the embryo. When the woman subsequently wishes to use the eggs, they are warmed (thawed) and fertilised using ICSI. If embryos develop, they are transferred, one or two at a time, to the woman’s uterus (womb).

Who is egg freezing suitable for?

We recommend egg freezing for all women who want to preserve their fertility for any reason. This may be for social reasons or for something as severe as a patient due to undergo chemotherapy for a cancer diagnosis. As women age, it becomes increasingly difficult to get pregnant, carry a baby to full term and deliver a healthy baby. Therefore we generally do not recommend egg freezing for subsequent use in women who are 38 years and older.

Sperm may be cryopreserved for a number of reasons:

  • If the quality of a semen sample is diminished, sperm may be frozen and banked to ensure adequate sperm are available on the day of treatment.
  • If a patient has physical or psychological problems with producing a semen sample.

Having frozen sperm in storage reduces the pressure to provide a sample on the day of treatment.

Some couples will have embryos frozen during their IVF / ICSI treatment cycle.

A FET cycle (Frozen Embryo Transfer) is a treatment that involves thawing frozen embryos and transferring them back to the womb.

Ovulation induction, egg collection and fertilisation are not required for a FET cycle, so it is much simpler than a fresh cycle. Success rates with frozen cycles are slightly lower than those with fresh cycles. However state of the art technology with vitrification is yielding excellent results.