To scratch or not to scratch?

The first step in our donor egg IVF treatment programme was to sync my menstrual cycle up to that of our egg-donor. As our embryo transfer was scheduled for almost three months from this point, the clinic asked me to go on the pill (specifically a monophasic pill) from my next period. Being on the pill meant that I could stretch out my cycle to catch up with that of the donor’s. Both the donor and I had to start our menstrual cycles on exactly the 10th July – the first day of our treatment cycle month.

The Czech clinic also recommended that I have an endometrial scratch performed. This is a procedure (somewhat similar to a smear/pap test for the patient) where a clinician uses a catheter to irritate the lining of the womb, causing a slight injury. The theory behind it is that this irritation elicits a “repair” reaction in the uterine lining, and releases hormones and growth factors which may also help an embryo to implant.

This is still a controversial procedure. Ask five fertility experts about it and you will probably get five different opinions as to it’s effectiveness. I asked my Maltese (consultant) Ob/Gyn for his professional opinion. He told me that he attended many Obstetrics and Gynaecology conferences and was shortly to depart for another. “It depends on which presentation I have just sat through”, was his reply.

Many clinics offer it only to patients who already had a number of failed embryo transfers in the past. Others offer it as an optional extra on top of their basic IVF (or embryo implantation) package. My Czech clinic recommended it, and even gave me a choice for when I got the procedure done. I could get it done the month before I started medications, or the month of the actual donor cycle. If I opted to have it performed during the same month as our donor cycle, I was to ask my clinician for a slightly gentler procedure – a “light irritation” as opposed to a “scratch”, was how they clinic described it.

I did some homework online and found a not inconsiderable amount of research suggested that having the scratch performed during the embryo implantation month actually resulted in a lower birth rate. Most of the research which supported the procedure recommended getting it done the month prior to the cycle month, specifically around day 21 (ie one week before our treatment cycle was to begin). A number of studies reported that it could improve birth rates if performed then, and while many of these studies suffered from having small sample sizes or from not being randomised trials, I weighed everything I read and decided to get the scratch done, and to have it done in the month before our treatment cycle. I felt that at best it might help. At worst, I didn’t think it would hurt.

My Ob/Gyn performed the procedure for me (at a fraction of the cost that many dedicated fertility clinics routinely charge patients) and thankfully, it was not as bad as I anticipated. I do not like smear tests – who indeed does? – and I did not find the endometrial scratch to be much worse than a smear. There were two uncomfortable moments, and it was over. Like anything, a lot depends on the doctor’s skill. If you are concerned about pain, you could take a painkiller an hour before the procedure. I was also told that I might spot a little afterwards. I did, but not much. In fact I could not even be sure that the spotting was down to the scratch, as I sometimes spot while on the pill anyway.

Now there was nothing more for me to do but finish my current contraceptive pill pack and wait for my withdrawal bleed. Bleeding would herald the first day of my treatment cycle month, Day 1 of when the medications were scheduled to begin.

The clinic had already given me a protocol (treatment plan) which was basically a spreadsheet listing the drugs I was to take over the 30-day cycle month. This would take me from the first day of medications, through to the embryo transfer day (estimated to be Day 18), and up to the day I would finally take a pregnancy test (approximately Day 30). If the test came back positive, I would then be issued with a new protocol for any drugs they wished me to continue taking for the rest of the first trimester.

If we could get that far.

There is a wealth of information related to this post available online, please take the time to look for the latest available publications.

Here is a small selection:

1. Performing endometrial ‘scratching’ once during IVF treatment can increase clinical pregnancy by 20% (downloadable pdf). 23rd World Congress on Ultrasound in Obstetrics and Gynecology, Oct 6-9th 2013, Sydney, Australia.
2. Endometrial Scratching (downloadable pdf). Midland Fertility Services.
3. Endometrial Biopsy “Womb Scratching”: Can It Double Pregnancy and Birth Rates? FertilityAuthority.com.
4. Coughlan C.J; Harrity C; Laird, S.M; Li, T.C. (2015). Local Endometrial Trauma (Endometrial Scratch): A Treatment Strategy to Improve Implantation Rates (Peer Review Draft). Royal College of Obstetricians and Gynaecologists.
5. Potdar, N; Gelbaya T; Nardo L. (2012). Endometrial injury to overcome recurrent embryo implantation failure: a systematic review and meta-analysis. Reprod Biomed Online. December, 25(6) 561-71.