Saturday, December 3, 2016

Behind The Science… Endometrial Scratch

Endometrial Scratch is a relatively new technique gaining significant attention

It was a friend who told Katie about a new procedure which might help after her first IVF treatment was unsuccessful. Known as endometrial scratch, it’s becoming increasingly popular with patients around the country and when Katie asked about the scratch at her clinic, she was delighted to find that they could offer it free along with her NHS treatment as it was a new technique they’d only recently launched.

The clinic explained the procedure would be carried out during the cycle before she started the treatment and Katie has just had her scratch. Now she is waiting to start her IVF cycle.

“I was petrified at the thought of having it done,” she admits. “I did take a paracetamol beforehand, but it was pretty much like a smear test and just felt like a normal period pain. It was a bit uncomfortable, but it was very quick and I didn’t have any other symptoms or bleeding.”

So what is the endometrial scratch?

Despite the name, it doesn’t actually involve any scratching at all, as Mostafa Metwally, a consultant at Jessop Fertility in Sheffield explains, “This technique has been used for some time in women who have had repeated unsuccessful IVF cycles and we think that by using some very mild form of endometrial trauma – that’s taking a small biopsy from the lining of the womb – it might actually improve their chances of getting pregnant. Taking a biopsy from the lining of the womb sounds a big deal, but it’s actually a very minor process and simply involves putting a small tube through the neck of the womb into the uterus that’s attached to a syringe-like structure. When you pull that syringe it creates negative pressure which takes a few cells from the lining of the uterus.”

Patients like Katie hope the endometrial scratch may improve their chances of success once she starts her treatment cycle, but as Jane Stewart, Consultant in Reproductive Medicine in Newcastle explains, there’s not yet sufficient evidence to say whether or not it is effective, so not everyone feels happy about offering the procedure to patients at this stage. “Whilst preliminary work seems promising it is not clear what the mechanism of action is with endometrial scratch,” she explains. “Well-conducted trials would clarify any effect which has yet to be validated. It is not a process that is ready for standard clinical practice and should only be undertaken in a research setting.”

Despite this lack of concrete evidence, some patients are asking for endometrial scratch and a number of fertility clinics do offer it. Penny wanted to try it in an attempt to boost her chances of success for her second IVF attempt. “It was part of our discussion when I went back when my first IVF cycle failed,” she explains. “I asked if there was anything I could do to make it more likely to be successful and they were honest enough to say it might help and it might not. It was a relatively new procedure for them I think.”

Staff at Penny’s clinic were honest with her about the lack of conclusive evidence, but she opted to pay £300 for the procedure. The patients I spoke to about their experiences had all been charged different sums; some hadn’t been charged at all, others had paid £100 or £150 and I heard reports that some patients had been charged as much as £500 for a scratch. Some clinics will only offer it when patients have had repeated unsuccessful IVF attempts and where there is more evidence to suggest it might work, but others will treat anyone who asks for it.

A number of the women I spoke to had tried the scratch more than once and still hadn’t been successful with treatment, but Penny felt that her £300 was money was well spent as she is now a mum after her second IVF cycle led to a positive pregnancy test. “The cost of it is peanuts compared to what people pay for a cycle,” she says,” and I think the scratch helped to make my womb lining more hospitable.”

In fact, no-one really knows for sure how or why having an endometrial scratch might improve the chances of success, but many of the theories do focus on the fact that it could make the womb a more accommodating place for implantation, perhaps by causing a response to the trauma of the scratch process.

Nick Raine-Fenning is a consultant at Nurture in Nottingham. “It’s got to be something to do with the basal layer of the endometrium (or womb lining),” he explains. “The best description came from a patient who said it was a bit like exfoliation – the problem with that is that when you have a period all the endometrium goes anyway, but with a bit of exfoliation hopefully the next endometrium which grows is going to be better. What ‘better’ means we don’t know – maybe it is more receptive, maybe the environment is better and if the embryo implants maybe the blood supply can develop better.”

“This technique has been used for some time in women who have had repeated unsuccessful IVF cycles and we think that by using some very mild form of endometrial trauma – that’s taking a small biopsy from the lining of the womb – it might actually improve their chances of getting pregnant.”

Raine-Fenning has been collaborating on research into the endometrial scratch with a team of scientists from Brazil, and initial results from the team showed an increase in pregnancy rates of around 20% in those who had the procedure. An earlier review of all the available research had also concluded that there seemed to be an increase in pregnancy rates when a scratch was carried out in the cycle before a treatment cycle, and Raine-Fenning’s team in the UK hope to have more results soon.

Much of the existing research has focused on women who’ve had repeated unsuccessful cycles of fertility treatment, but in Sheffield consultant Mostafa Metwally wants to find out whether the scratch could help in the first IVF cycle, and is working on a research project to look into this. If it is shown to be successful, he suggests that there could be wider implications for women who aren’t even having IVF, for those who have had repeated miscarriages or for couples with unexplained infertility.

Women are usually told to take some painkillers before they have an endometrial scratch as it can cause some discomfort. Period-like cramps are not uncommon, but occasionally the procedure can be more of a challenge. Vicki had an endometrial scratch before she started treatment, and was told that she might find it briefly painful. “I laid there and I was thinking this isn’t too bad,” she explains, “and then suddenly I was screaming and my knees flung up in the air. The nurse was looking at me with such sympathy. It was literally just for the 10 seconds while it was done. It was fine afterwards, you wouldn’t have known you’d had it done, but it was 10 seconds of agony!”

Despite the pain, Vicki had been determined to have the scratch although she’d never had any IVF treatment before. She had to pay for her treatment privately and knew she could only afford one cycle of IVF after unsuccessful IUI, so she had asked the fertility clinic to throw everything they could at it, including endometrial scratch. They agreed, and Vicki is now expecting her first baby.

Of course, she’ll never know whether the scratch made a difference, but more research data can’t come soon enough for patients who are keen to discover whether the scratch will be just another trend that turns out to be a shortlived wonder, or whether it could be a real step forward in fertility treatment for the future.

“The best description came from a patient who said it was a bit like exfoliation – the problem with that is that when you have a period all the endometrium goes anyway, but with a bit of exfoliation hopefully the next endometrium which grows is going to be better. ”

Kate Brian
A former Channel Four News journalist, Kate is the author of The Complete Guide to IVF and Precious Babies. She’s the London representative for Infertility Network UK and Editor of the Journal of Fertility Counselling. Kate’s children were both IVF babies, and she specialises in writing about fertility.

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