Endometrial injury for unexplained infertility: Arandomized case-control study

Endometrial injury for unexplained infertility: Arandomized

case-control study

Ayman M. Assaf, MD(1), Samy A.Saad, MD(1),Khaled M. Salama, MD (2 ),Ali Abdelnaby A. Morsy, M.Sc.(3)

1. Professor of Obstetrics and Gynecology, 2. Assistant professor of Obstetrics and Gynecology, 3..Assistant Lecturer of Obstetrics and Gynecology.

Department of Obstetrics & Gynecology, Faculty of Medicine, Benha University, Banha, Egypt

Abstract

Objective:we aimed at ,evaluating endometrial and sub endometrial vascular changes before and after endometrial injury, and evaluating the value of endometrial injury in improving pregnancy rates among patients with unexplained infertility .Methods :One hundred and twenty women with unexplained infertility were included in the study .Divided randomly into two groups Group I: (60 patients): (control group) Group II (60 patients):( study group) All the patients received (CC) and HMG,On day 5 of the cycle, Doppler examination was performed to all patients. Also on day 5, but only for group (II} patients, local endometrial injury was performed. Doppler studies was repeated, for all our patients, on the same day of prescribing HCG .Results :there was no statistically significant differences between the two groups in uterine PI and RI in in day of HCG, administration..the sub endometrial blood flow was statistically higher in the study group compared to control group(55% vs 20% ) (p value 0.001**) on the day of HCG. clinical pregnancy rate was significantly higher in the study group than in the control group (18.3 % and 6.7 % ,respectively,( P = 0.053) .Conclusion :Local endometrial injury increase pregnancy rate in un explained infertility ,Doppler study has an important role in evaluating sub endometrial blood flow before and after local endometrial injury .Based on our conclusions we may recommend local endometrial injury in un explained infertility .Key word :unexplained infertility, , endometrial injury, pregnancy

Introduction

Unexplained infertility, usually refers to a diagnosis (or lack of diagnosis) made in couples in whom all the standard investigations such as tests of ovulation, tubal patency and semen analysis are normal. Unexplained infertility is a term that has been applied to as many as, 30–40% of infertile couples (Smith et al., (2003). The potential causes of unexplained infertility was described as disturbances in endocrinological balance, immunology and genetic and reproductive physiology (Pellicer et al., 1998). None of these causes was solely able to explain all cases of reproductive failure. Empirically, interventions for managing unexplained infertility had been widely practiced. These interventions include expectant management, intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF)/ICSI, (El - Toukhy et al., 2008 ).Some ultrasonographic studies demonstrated that a substantial proportion of women with successful pregnancy had more optimal uterine blood flow and a thicker endometrium (Noyes et al., 1995) with more organized morphology (Serafini et al., 1994) compared with women without conception. In particular, increased uterine artery (UtA) vascular impedance (Zaidi et al., 1996) and low subendometrial or endometrial blood flow (Chien et al., 2002) have been associated with poor pregnancy rates. However, other studies did not revealed such associations (Puerto et al., 2003).The presence of both endometrial and subendometrial flow is indicative of good endometrial receptivity, (Chien et al., 2002).To improve blood flow to the uterus, some medications were suggested e.g low-dose aspirin (Weckstein et al., 1997) , vaginal sildenafil (Sher and Fisch, 2002), Vaginal micronized estradiol (Tourgeman et al., 2001),Antifibrotic as pentoxifylline (Trental) and high-dose vitamin E (Ledee-Bataille et al., 2002).

Implantation requires synchronization between the developing embryo and endometrium. The dialogue between embryo and endometrium and the receptivity of the latter is under the control of the sex steroids, estrogen and progesterone as well as other hormones (Kodaman and Taylor, 2004).Implantation failure remains one of the major factors limiting success in in vitro fertilization (IVF) treatment. According to the ESHRE data on assisted reproductive technology outcomes across Europe in 2009, only 32% of fresh embryo transfers resulted in clinical pregnancies (Ferraretti et al., 2013).Recently, in order to improve outcomes in women with unexplained RIF, various studies have examined pregnancy rates after inducing local endometrial injury,(Almog et al., 2010 and Zhou et al., 2008). It has been shown that mechanical manipulation of the endometrium can enhance receptivity by modulating gene expression of factors required for implantation like glycodelin A (Mirkin et al., 2005), lamininalpha 4, integrin alpha 6 and matrix metalloproteinase 1 (Almog et al., 2010 and Zhou et al., 2008).