Although there has been a substantial decline fertility experts offering the intrusive IVF treatment process of endometrial scratching, a third of them are still offering this often-painful procedure, despite a lack of evidence of benefit, found an international study in Human Fertility.
The survey of fertility clinic experts found that only 10% of them actually believe endometrial scratching improves pregnancy and live birth rates during the first round of IVF. The results from more than half (55%) of the respondents suggest that endometrial scratching is only offered to patients for psychological reasons, rather than medical, as it is often a “last resort” treatment option for those who have failed with several rounds of IVF.
“Many participants felt that endometrial scratching reduces distress among women who request it and offers hope to others who have had unsuccessful treatments; however, more research will be needed to clarify whether this does have psychological benefits for patients,” said lead researcher Dr Sarah Lensen from the University of Melbourne, Australia.
As many as 10% of couples experience subfertility, defined as the failure to conceive after at least one year of trying for a baby. Assisted conception methods are available to help these couples fall pregnant, including medication to assist with ovulation and in vitro fertilisation (IVF), where sperm and eggs are collected for fertilisation in the laboratory before an embryo is transferred directly into the womb.
Endometrial scratching, in which a small scratch or tissue biopsy is made in the lining of the uterus prior to IVF, is offered as an add-on therapy in some fertility clinics. It has been suggested that injury to the lining of the uterus may somehow increase the chance of an embryo implanting, and therefore pregnancy. Issues, however, include pain or discomfort and additional costs.
Initial studies suggested a potential benefit from endometrial scratching in IVF, especially in women with previous implantation failure. However, many of these studies were deemed to be of poor quality and had a high risk of bias in their design.
In 2015, a survey of clinics in Australia, New Zealand and the UK found that 83% of fertility specialists surveyed would recommend endometrial scratching before IVF, especially to women who have failed to get pregnant due to recurrent implantation failure. Since then, several large, randomised trials have reported no clear benefit of endometrial scratching for improving pregnancy or live birth rates.
To uncover current endometrial scratching views and practices, this latest study anonymously surveyed 121 fertility specialists, embryologists, and fertility nurses, online, between October and December 2020. Participants, from Australia (67%), the UK (25%), and New Zealand (8%), were asked about their views on benefits of the procedure; their clinic’s policies or stance; as well as their thoughts on the advantages and disadvantages.
Results showed an apparent reduction of the treatment over five years, but 34% of clinics still offer or recommend the procedure, usually associated with recurrent implantation failures.
Almost one in three respondents believed it increases the chance of success for women who have failed to get pregnant after several rounds of IVF.
What also emerged from the survey is that almost all respondents agreed that pain or discomfort is a major disadvantage, while more than half viewed the cost, inconvenience, and adverse effects as further issues.
Said Lensen: “The use of endometrial scratching appears to have reduced over time, probably after recent publications of studies which do not report that the procedure improves the chance of having a baby. This is an encouraging finding, as it’s clear that many IVF providers do respond to new evidence as it emerges.”
The authors note several limitations of the study, including the low response rate and that respondents with strong views about endometrial scratching (for and against) are more likely to complete the survey, which could limit the generaliseability of the findings to all fertility care providers. The survey was also restricted to three countries, so the findings might not be generaliseable to other populations.
Study details
Endometrial scratching in Australia, New Zealand and the United Kingdom (UK): a follow-up survey.
Madina Sarwari, Kiri Beilby, Karin Hammarberg, Martha Hickey, Sarah Lensen.
Published in Human Fertility on 14 December 2021
Abstract
Endometrial scratching is a common IVF add-on. In 2015, a survey in Australia, New Zealand and the United Kingdom (UK) reported that 83% of fertility specialists recommended endometrial scratching for IVF. Several large trials have since been published reporting no clear evidence for improved live birth rates after endometrial scratching before IVF. An online survey was undertaken to ascertain the current practices and views across Australia, New Zealand, and the UK. A total of 121 eligible responses were received between October and December 2020 (fertility specialists (n = 61), embryologists (n = 26) and fertility nurses (n = 24)).
Among fertility specialists, 34% currently offer endometrial scratching, mostly in the case of recurrent implantation failure. Most respondents were neutral or did not believe endometrial scratching improved pregnancy and live birth rates (>90%), except for in women with recurrent implantation failure (29% believed it can increase pregnancy and live birth rates in this group). More than half of respondents viewed reducing psychological distress as a benefit of endometrial scratching (55%). Among fertility specialists not offering endometrial scratching, 51% previously offered it but no longer do. The decline in use over the past five years likely reflects a response to recent evidence reporting no benefit from the procedure.
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