Friday, August 05, 2011

How to improve a poor uterine lining



One of the most frustrating problems in IVF today is the patient with a persistently poor ( thin) uterine lining.

Normally, the endometrium should grow and become thick ( more than 8 mm) and trilaminar as the follicles grow, so that it is receptive and ready to accept the embryos when they are transferred into the uterine cavity.

However, sometimes this does not happen.

We do know that the growth of the endometrium depends upon:
the estrogen level in the blood
blood flow to the uterus
and
the health of the endometrial tissue itself

A problem with any of these will cause the uterine lining to remain poor.

Thus, poor estrogen levels will cause the lining to remain thin. This is commonly seen in patients who have a poor ovarian response . It's easy to check this by testing the estradiol level in the blood. If this is low, this is easy to treat by giving estradiol valerate.




As with any other tissue, the uterine lining needs an adequate blood supply to develop optimally. Uterine blood flow can be measured by doing a colour Doppler. While it was originally hoped that this would provide useful information, sadly we still do not know what to do with this data. Doctors have tried improving uterine perfusion by treating these patients with vasodilators
( such as vaginal viagra and nitroglycerine patches), but the results have been mixed.

Sometimes, it's the endometrial tissue itself which has been damaged. This is often seen in patients who have had endomterial TB ( tuberculosis) in the past. Similarly, uterine surgery can also disrupt the uterine lining. We find this in women who have had a D&C ( dilatation and curettage) done after having had an anembryonic pregnancy ( missed abortion). Over-enthusiastic curettage can result in the removal of the basal layer of the uterine lining, called the basalis . Once this has been denuded, new endometrial tissue cannot grow and the lining remains persistently thin, resulting in a variant of Asherman syndrome which is very difficult to treat. ( This is why we tell patients who have had a missed abortion to terminate their pregnancy medically with mifegest and misoprostol, and to not do a D&C.)

The other common iatrogenic reason for a poor uterine lining is a hysteroscopic metroplasty which many aggressive doctors do for infertile women to "treat" a narrow uterine cavity ( which is a normal anatomic variant , and should be left well alone !)

If a patient has an unexpectedly poor lining during an IVF cycle, it's often best to freeze all the embryos rather than transfer them in the fresh cycle. We can then work on improving the uterine lining before transferring the frozen embryos back into the uterus.

If patients have a history of a poor lining, we use the following protocol to see if their lining responds to an increased dose of estrogen.

This is the protocol we use.

Tab Lynoral ( ethinyl estradiol) , 0.05 mg , 1 tab daily with dinner, from Day 1 – Day 25.
We do a vaginal ultrasound scan on Day 12 to check the endometrial thickness and texture.
If this is fine, we then include a period by giving Tab Deviry ( medroxyprogesterone acetate) , 10 mg, twice a day from Day 16-25.
We can then transfer the embryos in the next cycle.

However, if the uterine lining remains persistently thin, we try doubling the dose of Lynoral and repeating the scan .

If it still does not improve, this confirms this is an end-organ defect in the endometrial tissue.
This can be very difficult to treat.

For these patients, we do a hysteroscopy, to confirm there is no correctable anatomic problem ( for example, adhesions) which we can remove.

We can also do an endometrial biopsy on Day 2 or 3 of the IVF cycle. This deliberate endometrial injury is supposed to provoke increased uterine blood flow, and sometimes causes the lining to improve.

We have also tried alternative medicine, such as using bromelain , 200 mg daily , to try to improve the uterine lining, but results are mixed.

A recent interesting paper ( Successful treatment of unresponsive thin endometrium, Fertility Sterility, 2011) has described the use of an intrauterine perfusion of Granulocye Colony Stimulating Factor ( G-CSF) . It is believed that the local delivery of cytokines and growth factors can improve the uterine lining. We are currently evaluating this experimental technique in our clinic and the initial results have been very promising.

For patients whose lining remains refractory to all therapeutic intervention, surrogacy is the final treatment option which has a very high success rate.






Enhanced by Zemanta

48 comments:

  1. The G-CSF seems like a clever idea, kudos to the group that came up with that one and I hope your trial works!

    ReplyDelete
  2. Thanks for the discussion...there are any woman who have queries and feel awkward to go ahead and ask...this could be a wonderful forum for such discussion.

    ReplyDelete
  3. where can i have G-CSF wash done in Asia?

    ReplyDelete
  4. We now do this routinely for patients with a thin lining

    Dr Aniruddha Malpani, MD
    Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
    Bombay 400 005. India
    Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

    Helping you to build your family !

    My Facebook page is at www.facebook.com/Dr.Malpani

    You can follow me on twitter at http://twitter.com/#!/drmalpani

    Watch our infertility cartoon film at http://www.ivfindia.com

    Read our book, How to Have a Baby - A Guide for the Infertile Couple,
    online at www.DrMalpani.com !

    Read my blog about improving the doctor-patient
    relationship at http://blog.drmalpani.com

    ReplyDelete
  5. Hi Dr, great post and blog. I am from China. My wife had TB when she was 14, and was completely cured then. We are now 29 and TTC for. 1 year with no luck. Dr suggest to check the tubes and then was found both are blocked. Followed is a hysteroscopy performed last month. Dr. said not possible to clear the tubes and remove the adhesion. One good thing is that no TB is found in endomterial lining. Then my wife took progynova for 21 days as the 1st session to build up lining but unfortunately find out that her lining was only 3mm. One Dr says wait the period and see how it goes, and the other Dr says the lining may never thicken! What is your opinion? Before the surgery, her lining was up to 5mm though. We pray the lining would grow at any cost. Pls advise!

    GAO.S

    ReplyDelete
  6. Anonymous9:11 PM

    Hi doctor, pls what would be your protocol for a pof patient using donor eggs. I dint have much problem growing the lining in my first failed cycle. But I just want ur advice/help to make sure my clinic does everytin right in my next cycle starting soon. Tank u.

    ReplyDelete
  7. Most POF patients have a normal uterus and will grow a good lining after taking estradiol valerate ( Progynova)

    ReplyDelete
  8. Anonymous11:47 AM

    Tanks for ur prompt reply. Am the POF poster above. I ve started my procedure and my clinic placed me on buserelin injection for 2wks after which I would take progynova. Do I realy need the buserelin cos they were not able to convince me. I have a feeLing they don't realy know the procedure for a POF patient.
    I got to 3weeks the laSt time b4 I started bleeding. I live 5hrs drive away from my clinic. Do you think I should travel back after my procedure?

    ReplyDelete
    Replies
    1. No, patients with POF do NOT need buserelin since you are naturally downregulated

      Delete
  9. Anonymous10:18 AM

    With reference to article "Vaginal sildenafil (Viagra): a preliminary report of a novel method to improve uterine artery blood flow and endometrial development in patients undergoing IVF." published in Human Society of Human Reproduction and Embryology, Human Reproduction vol. 15 no. 4 pp.806-809, 2000; what is your opinoin on success of treatment by using Sildenafil Citrate with Estradiol Valerate as new combination therapy. Also what precaution you will suggest in this therapy and possible side effects from which patients can suffer.

    ReplyDelete
    Replies
    1. Most doctors have stopped using vaginal viagra - unfortunately, it does not work well

      Delete
  10. Anonymous7:46 PM

    Hello sir,
    Is thickness of 6.5 to 7.5 mm enough for IVF success?
    I have had a few rounds of IVF failures and my lining hardly reaches 8 mm now.
    I had TB 7 years ago due to which my tubes got blocked.
    Is thin lining in my case due to TB?
    I do not have adhesions or any other problem in uterine cavity as mentioned in laparoscopy. But my lining has also reached 9 mm few years ago as seen in scan but recently it hardly surpasses 7 mm. What could be the reason?

    ReplyDelete
    Replies
    1. It's hard to provide a reason for a thin lining in most patients.

      Have you tried intrauterine perfusion of Granulocye Colony Stimulating Factor ( G-CSF) ?

      Delete
  11. Dear Sir,
    Thank you for such helpful blog.

    I came to know about one formulation called ALIVHER ES which contain Sildenafil citrate (25mg) and Estradiol valerate(2mg) in combination. Could you please suggest me that for what purpose it is used and by which administration route it should be taken.

    ReplyDelete
  12. Dear Dr
    I am taking progynova (4 tablets ) and oestrogel .I am on day 21 of my cycle .My endometrial linning is 7mm today.My Dr wants me to continue the medication for 5 more days.Is this normal I have heard after certain time endometrial linning becomes old may not be optimal for implantation.I am doing FET this cycle.How many days of progynova and oestrogel is generally recomended before FET.

    ReplyDelete
    Replies
    1. This varies from woman to woman. No, the lining does not get "old", so please be patient

      Delete
  13. Thank you so much Dr

    ReplyDelete
  14. Dr. I have endometrial adhesions due to uterine tuberculosis. How will it be removed?

    ReplyDelete
  15. How was this diagnosis of uterine TB made ? These TB PCR tests are very unreliable ! You can read more about this at http://blog.drmalpani.com/2015/03/laboratory-tb-versus-genital-tb.html
    Please do NOT waste your time and money or risk your health with the toxic antiTB drugs

    ReplyDelete
  16. Doctor;

    My doctor suspected i have endometriosis hyperlasia. What other method can induce period aside from dilation & curretage procedure?

    ReplyDelete
  17. You can induce a period with progesterone tablets. Tab Meprate 10 mg, twice a day, for 5 days. The period will start 3-6 days after the last tablet

    ReplyDelete
  18. Hello Doctor,
    My doctor told me that i have uterine & vaginal septum. She has done Hysteroscopy & laparoscopy last month. She has removed uterine septum but vaginal septum cut down in 2 parts only. She told after laparoscopy that the tubes are blocked- One at end & other at starting. Now she gave me Progynova tablets. Please suggest how vaginal septum can be removed?

    ReplyDelete
    Replies
    1. A vaginal septum will not affect your fertility !
      Why are you taking progynova if your tubes are blocked ?

      It seems you have tubal factor infertility. You can read more about this at www.drmalpani.com/knowledge-center/articles/blockedtubes

      I am sorry there is no way of repairing damaged fallopian tubes, as they cannot function normally
      even after surgery, since their inner lining ( the cilia) has been damaged.

      I agree that IVF would be your best treatment option
      as it would maximise your chances of conceiving quickly.

      Treatment takes about 20 days. Should I send you the treatment plan ?

      I need more information to be able to provide you with intelligent advice.

      Could you please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better?

      You can read about more about how we take care of our patients at http://www.drmalpani.com/ivf-treatment-at-malpani-ivf-clinic.htm

      You can talk to some of our patients by email at http://www.drmalpani.com/success-stories.htm

      Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !


      We look forward to helping you to have a baby !

      Dr Aniruddha Malpani, MD
      Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
      Mumbai 400 005. India

      Clinic Mobile: 9867441589

      Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

      Helping you to build your family !

      You can add a google review for us at https://plus.google.com/102706636605134081909/about

      My Facebook page is at https://www.facebook.com/aniruddha.malpani

      You can follow me on twitter at https://twitter.com/drmalpani

      Watch our infertility cartoon film at http://www.ivfindia.com

      Read our book, How to Have a Baby - A Guide for the Infertile Couple,
      online at www.DrMalpani.com !

      Read my blog about improving the doctor-patient
      relationship at http://blog.drmalpani.com

      Delete
  19. Hi Doc,
    In my last IVF cycle, i had two blastocyst transfer.Doctor said apparently the embryo quality was good..moreover my endometrium thickness was 9.4 with good texture.in spite of that the cycle was a failure..what may be the cause of the failure

    ReplyDelete
    Replies
    1. It's always hard to pinpoint a specific cause for IVF failure, since there are so many variables need to go right for implantation to occur

      I need more information to be able to provide you with intelligent advise.

      Can you send me more details about your IVF cycle ?
      DO YOU HAVE PHOTOS OF YOUR EMBRYOS ?

      You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos

      What were the meds which were used for
      superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? What was the endometrial thickness ?
      How many embryos were transferred ?
      What was the embryo quality ?
      Can you please send me the printed treatment summary from your IVF clinic ?

      We look forward to helping you to have a baby !

      Delete
  20. Hello doctor, I have bicournate uterus and had 2 miscarriages in past. My doctor has prescribed me the above mentioned medicines, lynoral along with. Deviry. I wanted to know is this medicines helpful in my case. Pls suggest. Thanks, Priyanka

    ReplyDelete
    Replies
    1. No, they will not help you.
      How was your diagnosis of bicornuate uterus made ?
      Are you sure it is not a septate uterus ?

      We look forward to helping you to have a baby !

      Delete
  21. Hello Doctor:
    Greetings!
    I have poor AMH level, and this is my first IVF. I am just lucky with one embryo which has reached the blastocyst. My lining during the IVF was 3.7 and the doctors recommended me to freeze the embryo which we did. She has put me on Progynova 1-1-2 along with Oestrogel 1-1. She has also tried the Endokine 300 MCG through the uterus. In spite of all this, the lining today is 4.6. She has suggested me for an embryo transfer on saturday, 5 days from today. I am based out out Hyderabad. Please suggest ..regards,
    Kanchan

    ReplyDelete
    Replies
    1. Please do NOT transfer if the lining is so poor

      Delete
    2. The doctor has recommended about the new technology on the stem cell and the other alternative is Surrogacy. which is a very big deal for us in terms of finance. Considering the lining from the last 2 cycles, what will be your recommendation doctor. My AMH level is 0.67, this reduces the possibility for the next cycle too. I dont know what steps to take. Please advise.

      Delete
    3. The stem cell stuff is a scam

      There are lots of ways to improve a thin lining. One option is to increase the estrogen dose

      The other is to try a natural cycle

      Best of luck !

      Delete
    4. Anonymous12:41 PM

      Hi Doctor,

      Age 36.Corrective surgery hysteroscopy done in US for thick adhesions 3 months back. After which HSG was done , it was found little more adhesions on the right top corner of uterus to be removed but otherwise was able to restore 80% normal uterine cavity. My endometrium lining in this cycle was CD13 6.1mm . Now , I would like to know if I could try IVF or wait for a second hysteroscopy to completely remove adhesions?? I m little worried about the cavity.Pls guide

      Delete
  22. How about too thick lining. My lowest lining was 10-12 mm after period with estrogen meds prior it gets to 20-22mm before IVF transfer. I feel the lining is too thick and how do you thin it down. Even after taking progesteron it only gets down to 10 mm after period.

    ReplyDelete
  23. You might have a uterine polyp. Your next step is a hysteroscopy ( www.drmalpani.com/knowledge-center/articles/hysteroscopy) to check the uterine cavity

    ReplyDelete
  24. Hello Sir,My wife is suffering from Thin Endometrium problem. Doctors which we have consulted and have tried everything but there has been no solution so far. My wife had a miscarriage few years back and doctor suspect that the miscarriage could have been due to thin endometrium. Doctor has now suggested for surrogacy.
    Will you be able to help with the thin endometrium problem ?

    ReplyDelete
    Replies
    1. Was a D&C done after the miscarriage ?
      I am worried she may have developed intrauterine adhesions after your D&C . This is called Asherman syndrome

      Read more at http://www.drmalpani.com/knowledge-center/articles/asherman

      Take the following

      Tab Lynoral ( ethinyl estradiol) , 0.05 mg , 1 tab daily with dinner, from Day 1 – Day 25.
      Vaginal ultrasound scan on Day 12 to check your endometrial thickness and texture.
      Email me this report.
      Then take Tab Deviry ( medroxyprogesterone acetate) , 10 mg, twice a day from Day 16-25.

      If the uterine lining remains thin, this suggests she has endometrial atrophy

      Delete
  25. Anonymous6:52 AM

    42y.o. G2P1 (1011), with a 7y.o son. Trying to get pregnant another this time. Had one cycle of Clomid last cycle which did not work. Started Letrozole twice daily for 5 days beginning day 2. Day 8 TVS showed thin lining at 0.5. How much Progynova and for how long would you suggest to achieve adequate lining thickness? Trying to conceive the natural way. Thank you so much.

    ReplyDelete
    Replies
    1. How big was your follicle on the scan ? The lining will improve as the follicle grows

      Delete
  26. Anonymous1:13 AM

    Dear Dr. I have been having endometrial fluid retention for over a year now. This was caused by a doctor who tried to pull out fibroids through my cervix and ended up not removing any fibroid but when and scrapped my endometrial walls without telling me. It is giving me issues conceiving and I have had a failed IVF.
    Please what do I do.

    ReplyDelete
    Replies
    1. Your next step is a hysteroscopy ( www.drmalpani.com/knowledge-center/articles/hysteroscopy) to check the uterine cavity and remove the intrauterine adhesions. Once the cavity is normal, we can then do IVF.

      Delete
  27. Hi dr..I am suffering with primary ammermonea.My age is 24..stil i never get my menstruation..Doctors are telling everything is fine..only problem with endometrium thickness..hormones,ovaries,uterus was normal.I don't have thyroid.I am done with hysteroscopy to check T.B for endometrium.that also normal.Please can you suggest where i will get nice treatment for to increase endometrium thickness.I want to get my periods.I want to give birth to children.At any cost Iam ready to pay..Please help me out..

    ReplyDelete
    Replies
    1. This is hard to explain

      Do you get a withdrawal bleed after taking estrogens and progesterone for 21 days ?

      Delete
  28. Hi Doctor,

    I have PCOD. I have gone through follicular study and found that my endometric layer reaches upto 6mm on 15thday of my cycle. My doctor suggested to take duphaston 10mg per day from 16th day of my cycle for 12days. Also she suggested miprogen 2tablets per day from 16th day of my cycle for 12days. My estrodial levels are normal as per the reports. Can you please suggest how can i proceed now. I think may be my fallopian tubes are blocked but i dont have any history of TB or miscarriages. I got married on 26th Feb 2016. Till date there is no chances of pregnancy :( please help

    ReplyDelete
    Replies
    1. Dear Priyanka,

      Your uterine lining is thin because you are not ovulating ( because of your PCOD)

      You can read more about how we treat PCOD at
      http://www.drmalpani.com/knowledge-center/the-infertile-woman/how-to-manage-your-pcod

      Do a complete workup before starting treatment haphazardly.

      You need to do ALL the following simple medical tests:

      semen analysis for your husband ( to check his sperm count and motility).
      Read more at http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

      blood tests for you for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( antiMullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs). Do this from a reliable lab such as SRL ( www.srl.in). Day 1 = Day the period starts.

      HSG ( hysterosalpingogram, X-ray of the uterus and tubes, www.drmalpani.com/hsg.htm) on Day 8 of your cycle ( to confirm
      your fallopian tubes are open);

      The vaginal ultrasound scan on Day 10-11 should check for the following. a. ovarian volume b. antral follicle count c. uterus morphology d. endometrial thickness and texture

      Please send me ALL the detailed test results and medical reports . You can scan them in as a single doc or pdf file and email them to me.

      Please send me all the results together, rather than piecemeal, so I can interpret them intelligently


      Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

      You can talk to some of our patients by email at http://www.drmalpani.com/success-stories.htm

      We look forward to helping you to have a baby !

      Regards,

      Dr Aniruddha Malpani, MD
      Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
      Mumbai 400 005. India

      Clinic Mobile: 9867441589

      Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

      Helping you to build your family !

      You can add a google review for us at https://plus.google.com/102706636605134081909/about

      My Facebook page is at https://www.facebook.com/aniruddha.malpani

      You can follow me on twitter at https://twitter.com/drmalpani

      Watch our infertility cartoon film at http://www.ivfindia.com

      Read our book, How to Have a Baby - A Guide for the Infertile Couple,
      online at www.DrMalpani.com !

      Read my blog about improving the doctor-patient
      relationship at http://blog.drmalpani.com

      Delete
  29. Anonymous11:29 PM

    Hello Dr
    I am going through my first Ivf....I had only 2 embryos of Day 3 which was frezzed Bcoz my ET was 5.8 during egg retrieval.. From then on I was taking progynova 2 mg twice a day and oestrogel 2 times a day plus folic acid-1 and ecosprin -1 for 28 days... My ultrasound report on day 14th (ET - 4.8) with fluid....on day 21st(ET-6.1) with fluid ...on day 28th (ET - 6.3) with fluid and blood flow was-(mild vascularity in zone 2)...As thickness was low and blood flow inappropriate,i was recommended to take meprate for 5days twice and had a period... ....Dese process goes on for 3 months in a row but the results are same... .Now my doctor advised me to implant the embryo as there is no improvement in ET. ...
    What will you suggest me.... Kindly reply...
    I had all the negative issues - low ET, blood flow in zone II only(minimal), embryos of Day 3,fluid in endometrial cavity
    Eagerly waiting for your reply
    Note: 1) I am a hypo hypo patient
    2)Doctor will take out the fluid during implantation process

    ReplyDelete
    Replies
    1. Not a good idea

      Your next step is a hysteroscopy ( www.drmalpani.com/knowledge-center/articles/hysteroscopy) to check the uterine cavity

      Do you have photos of your embryos ?

      Delete
    2. This comment has been removed by the author.

      Delete
    3. Anonymous11:40 PM

      I had sent u an email attaching my reports In it at [email protected] give your valuable advice.... I had to take decision of hysteroscopy soon. .. Please guide me doctor.... Please check my mail that I had send you

      Delete

Get A Free IVF Second Opinion

Dr Malpani would be happy to provide a second opinion on your problem.

Consult Now!