It’s never easy to reverse a long held opinion. But in order to keep improving what we do, we must be open-minded to change. I remind myself of this perspective whenever I encounter a new study that contradicts a long held belief. Recently, I started reconsidering my skepticism on “scratching” or taking an endometrial biopsy in order to better prepare a woman’s uterus for embryo implantation.
The way I was trained, it was imperative that we perform an embryo transfer without causing any trauma to the endometrial lining. Oftentimes we worked through difficult transfers in order to minimize the risk of getting a spot of blood on the catheter as it was felt to be an ominous sign. Blood on the catheter tip was believed to reduce the chance for successful implantation. Recent studies suggest that in some cases the opposite may be true. Let’s first consider the theory behind this potential benefit.
Following any damage to the endometrial lining, chemicals called cytokines are released which promote healing of the injury. This healing process promotes what is called decidualization which also encourages implantation. Decidualization can also help slow the changes that are occurring in the endometrium—another benefit since the hormone levels associated with IVF can accelerate endometrial growth and therefore make the uterine lining out of synch with the actual embryo development. Whether some or all of these changes are responsible there have been a few studies now that have looked at the impact that inducing an endometrial injury can have upon embryo implantation.
A recent review [r1] of the five published studies on the effects of performing an endometrial biopsy prior to or during and IVF cycle was even more revealing. They found that four of these studies demonstrated that endometrial biopsy significantly improved implantation—suggesting that in some patients it may even double success rates. They also found that the timing of the biopsy was critical. In the one study[r2] that involved performing the biopsy on the day of the egg retrieval, they found a dramatic reduction in the implantation and on-going pregnancy rate; an observation that validates my previous doubts about “scratching” the endometrium. So before you request this treatment consider the following:
- Discuss with your doctor whether you may have had an implantation problem or if your previous unsuccessful cycles were due to poor embryo quality.
- Request this procedure be performed before the menstrual cycle of the month you wish to proceed with IVF (prior to starting ovarian stimulation meds)
- Endometrial biopsy can be uncomfortable so consider the use of an anti-inflammatory about an hour or so before your procedure
Robert Greene, MD, FACOG
CNY Fertility Center
e-mail me at robertg@conceptionsrepro.com
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Enhancing Fertility 
When is it recommended to have this done if you are using DE and not OE? Also, is it recommended to have this done more than once before a person has ET? If So, how often and when should the person start in comparison to the ET?
Thank you!
Dear Jennifer,
The studies demonstrated that a single endometrial biopsy performed during the luteal phase (Second half) of the cycle before the planned transfer is associated with increased implantation rate. I am not familiar with the terms “DE” or “OE.” I do hope that this answers your question.
Best thoughts,
~Robert
Robert Greene, MD, FACOG
CNY Fertility Center
Hello Dr. Greene,
Thank you for taking time to answer the question.
DE = Donor Egg and OE = Own Egg
So, anytime after ovulation but before your last menstruation you will have before you go through with the transfer? I just wondered if this would be different for someone using donor egg vs. own egg?
Thank you again.
Jennifer
I will be receiving my next embryo transfer in January, which will be try #4 for IVF. I am using donor eggs, so there is no ovarioan stimulation for me. Also, this ET will be a Frozen Embryo Transfer. I have never done the endometrial biopsy protocol. My doctor is recommending two biopsies, in the two weeks leading up to the beginning of my del estrogen medication. I am curious as to your thoughts-why two biopsies instead of one? Thanks, Lori
I have not seen data demonstrating a more beneficial effect from two biopsies. i would encourage you check with your doctor to see what they are basing their recommendation upon. They may have some unpublished data or there may a reason specific to your situation.
Best thoughts,
~Robert
Robert Greene, MD, FACOG
CNY Fertility Center
I am confused on when the biopsy should take place.
I had my first biopsy before my fourth failed fresh embryo transfer. I will have a frozen embryo transfer soon (date tbd). My biopsy is on Jan 14. When are the ideal dates for my frozen transfer.
Dear Chris,
Thank you for seeking clarification. I cannot offer specific medical advice; that should only be offered by your doctor/medical team as they are most familiar with the specifics of your situation. Typically, we recommend the biopsy should be done during the luteal phase of the cycle prior to the planned transfer. Typically, that would be about 3 weeks (give or take a few days) prior to the FET. Please check with your center to see if this advice is appropriate for you.
Best thoughts,
~Robert
Robert Greene, MD, FACOG
CNY Fertility Center
That’s perfect information. It will work out to be about 3 weeks before.
Thank you,
chris
Hello Dr. Greene,
I received my results from my biopsy and plasma cells were found. It is less than the amt that was found from my biopsy in Nov/Dec however, plasma cells were found and I am going back on antibiotics for 10 days. Should I:
A. Cancel my cycle (transfer date on Feb 7) and wait until I get a clean biopsy or
B. Continue with my scheduled frozen embryo transfer because I may never get a clean biopsy because the inflamation may never be fully addressed by the antibiotics?
Many thanks,
chris
Dear Chris,
Unfortunately, this is not a simple question to answer. Therefore, it is most appropriate for you to review this with your doctor so that they may discuss with you what they feel is most appropriate in your clinical situation. I wish I could guide you more specifically but I do not know enough about your clinical history.
Best thoughts,
~Robert
Robert Greene, MD, FACOG
CNY Fertility Center
Dr. Greene,
In what circumstance would you recommend the Beta 3 integrin test with the biopsy? Can you explain a little about what it means for fertility to be lacking in this protein?
Denise
Dear Denise,
I have fairly unimpressed with the data on the usefulness of Beta 3 integrin testing. More importantly, there is little data that it provides us with any appropriate intervention. What are your thoughts? Has your doctor recommended it? If so, what did they propose as a treatment if the test indicates that treatment is warranted?
Best thoughts,
~Robert
Robert Greene, MD, FACOG
CNY Fertility Center