• Physician-To-Physician Consult

Thin endometrium at the late follicular phase: How should we react?

Dear Colleague,

I have a patient who is 31 years old. She was stimulated for her first IVF with hMG 150 IU per day for 7 days. The estradiol level reached 3400 pmol/l and the follicles reached 17 to 22 mm in diameter in both ovaries. Unfortunately, the endometrium remained 3-4 mm in thickness. Egg collection was done, 11 eggs collected, 8 fertilized, 5 blastocysts were developed and 2 replaced, 3 were cryopreserved. The patient did not conceive.

How would you recommend to proceed?

View Answers

Answer by Zeev Shoham

Based on our experience I would like to suggest doing an endometrial irritation during menstruation, using the pippele catheter and replace one blastocyst if the endomnetrium will reach 6-8 mm in diameter along with follicular development. i.e. to follow a natural cycle while doing a pippele during menstruation.

Zeev Shoham

Answer by Ariel Weissman

I would like to look at the patient's history and look for a reason (correctable?) for her thin lining. I would be more relieved if her thin lining is "primary" (no procedures or instrumentation were carried out in the past on her uterine cavity). If the patient was subjected to D&C or endomeritis in the past, I would start to worry... In any case, I would not proceed without a diagnostic hysteroscopy, which could be combined with pipelle biopsy as suggested above. I would than proceed to frozen embryo transfer during a natural cycle, and if there is insufficient lining build-up I would switch to estrogen replacement therapy, including transdermal and vaginal estrogen.

Ariel Weissman

Answer by Norbert Gleicher

I agree with need for a full work up to diagnose potential underlying causes. In the end, however, the treatment approach will, likely, remain the same.
I cannot respond in regards to endometrial irritation for lack of personal experience, though the literature appears to increasingly support such a response in cases of implantation failure.
I am, however, unclear whether such a response has been reported to help in cases of unresponsively thin endometrium. My suggestion would be to perform a mock cycle to see whether
the patient's endometrium can be expanded with routine treatments, such as increased estradiol dosages (transdermal, vaginal and oral) and Viagra (or beta-blockers; we use Atenolol). If she reaches 7mm,
I would give her the same treatment in a regular IVF cycle or FET cycle. If she does not reach 7mm thickness, I would attempt expanding her with an endometrial infusion Granulocyte Colony Stimulating Factor (G-CSF), as we reported initially in Fertility & Sterility and more recently in Human Reproduction in a larger case series of women with otherwise resistant endometrium.

Norbert Gleicher, MD

Answer by Ilan Tur-Kaspa

I addition to all of the above comments, I would monitor her natural cycle to evaluate her 'baseline' endometrial thickness. If she'll have a normal hysteroscopy and she'll have over 7-8 mm of endometrial thickness, ET may be performed without any other interventions. 

Prof Ilan Tur-Kaspa
www.infertilityIHR.com

Answer by Andre Hazout

It was not necessary to transfer two blastocysts in such endometrium. You could vitrify the embryos and make an assessment ; It depends on the history of the patient.An hysteroscopy is indicated to evaluate the endometrim status. If the cause is not iatrogenic, I agree with the proposed treatment (estrogen, viagra, G-CSF etc..)elsewhere, emphasizing the research of subclinical infection. Note also the role of melatonin on the endometrial growth. Unfortunately in our experience it is not easy to restore a normal endometrium with the best receptivity.Endometrium biopsy is not recommended if the endometrium is very thin and often not informative unless if you have the opportunity to perform a genomic profile

Answer by Harry Siristatidis

I agree with all the above. If it is <6mm, you freeze (vitrification is a simple good solution). Hysteroscopy is indicated in most of the cases to make a clearer judgment. You do not procced with endometrial injury, unless you have an indication of doing so - and thin endometrium is not an indication. Then you monitor 1 - I would say 2- natural cycles, to check if this is being repeated, or it was accidental. If it remains the same, you go for HRT/FRC, as mentioned above, with high rising dosages of oestrogens.

Harry Siristatidis

IVF Unit, Attikon University Hospital, Athens, 12642, Greece

Please Login/Create Account for adding a new answer

The site is not a replacement for professional medical opinion, examination, diagnosis or treatment. Do not delay seeking or disregard medical advice based on information written by any author on this site. No health questions or information on IVF-Worldwide.com is regulated or evaluated by the US Food and Drug Administration or any other administration, and therefore the information should not be used to diagnose, treat, cure or prevent any disease without the supervision of a medical doctor. Posts made to these forums express the views and opinions of the author only, and serve as an open forum to discuss clinical issues among experts in the field.

Threesome
Creampie
Blowjob
Blowjob
Orgy
Creampie
Creampie
Orgy
Blowjob
Creampie
Threesome