http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecol Endocrinol, 2014; 30(7): 481–484 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2014.900747
EMBRYO TRANSFER IN THIN ENDOMETRIUM
Live birth after embryo transfer in an unresponsive thin endometrium Fa´bio Cruz1 and Jose´ Bellver1,2,3 1
Instituto Valenciano de Infertilidad, Valencia, Spain, 2Fundacio´n IVI, Instituto Universitario IVI, University of Valencia, Valencia, Spain, and Department of Pediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
3
Abstract
Keywords
A healthy term livebirth in a 35-year-old woman with ovarian failure, hypoplastic uterus and atrophic endometrium after cancer treatment with chemotherapy and radiotherapy was achieved by ovum donation. The detection of a receptive endometrium using a new diagnostic tool of endometrial receptivity encouraged the medical team to carry on with this poor prognosis case. To the best of our knowledge, here we report the thinnest endometrium to date in which a healthy, full term live birth has been described in assisted conception.
Atrophic endometrium, endometrial receptivity, endometrial receptivity array, live birth, uterine radiotherapy
Introduction Endometrial receptivity is essential for successful embryo implantation [1]. An endometrial thickness 7 mm has been related to better implantation rates [2,3]. Nevertheless, pregnancies and live births have been recorded with thinner endometria [4–6], and pregnancy failures also occur in morphologically normal endometria [7]. Unresponsive thin endometrium is usually related to previous vigorous curettages, infection, Asherman’s syndrome or uterine irradiation [8]. The reproductive outcome is consistently poor in this situation. In recent years, several strategies have been suggested to improve the endometrial thickness and quality, such as administration of extended or high estrogen therapy [9,10], pentoxyfilline [11,12], tocoferol [11–13], arginine [14], sildenafil citrate [15] or even intrauterine perfusion with granulocyte colony-stimulating factor [16] and autologous uterine stem cell therapy [17] (Table 1), with poor, unknown or inconsistent results. Adoption or surrogacy is chosen in severe cases, but social, economic or legal restrictions make these options not frequently available.
Case report A 35-year-old woman with a 2-year iatrogenic ovarian failure came to our center seeking reproductive advice. As a consequence of M4 acute myeloblastic leukemia, she had undergone chemotherapy and radiotherapy prior to bone marrow transplantation consisting of induction chemotherapy with idarubicin and cytarabine, followed by a conditioning regimen which included anti-thymocyte globulin, cyclophosphamide and total body irradiation on two consecutive days (6 Gy/day). She suffered
Address for correspondence: Jose´ Bellver, M.D., Instituto Valenciano de Infertilidad, Plaza de la Policı´a Local, 3, 46015, Valencia, Spain. Tel: +34 963050900. Fax: +34 963050999. E-mail: [email protected]
History Received 6 October 2013 Revised 10 February 2014 Accepted 27 February 2014 Published online 20 March 2014
from two graft-versus-host diseases treated with corticosteroids and immunosuppressants, and finally went into remission. At her first visit, the ultrasound examination showed atrophic ovaries and a hypoplastic uterus (5.5 cm 2.7 cm 3.2 cm) with a very thin endometrium. Oral estrogen therapy with 6 mg/day of estradiol valerate (Progynova, Bayer, Spain) was given for 20 days to assess the endometrial response, but the maximum endometrial size achieved was of only 3 mm. Afterwards, two more courses of estradiol valerate with increasing doses were given for 6 weeks (first week: 2 mg/day; second week: 4 mg/day; third week: 6mg/day, and 8 mg/day from the fourth week), and 800 mg/day of vaginal micronized progesterone (Progeffik, Laboratorios EFFIK, Spain) were added in the last 2 weeks to induce menstruation. In both courses, serum estradiol concentrations achieved were 636 and 1092 pg/ml, respectively, but the endometrium never became thicker than 3 mm and showed a dense echogenic pattern. Hysteroscopy showed a short cervical channel, a hypoplastic uterine cavity with a small subseptum, and a thin, atrophic and hyperemic endometrium with a left horn completely covered by fibro-connective adhesions (Figure 1) which relapsed despite three hysteroscopic surgeries and administration of high-dose estrogen therapy between them. Pathological examination of random biopsies showed some proliferative areas. In a fourth hysteroscopy (Figure 2), after estrogen therapy and 3 days of 800 mg/day of micronized progesterone, an endometrial biopsy was taken showing minimal secretory changes and a ‘‘receptive’’ endometrium according to the Endometrial Receptivity Array (ERA) test. The ERA consists of a newly developed customized array containing 238 genes expressed at the different stages of the endometrial cycle, coupled to a computational predictor designed to identify the receptivity status of an endometrial sample and to diagnose the patient’s window of implantation (WOI) regardless of the histological appearance of the sample [18,19]. The ERA test classifies the endometrial samples as receptive or not receptive with an associated diagnostic probability. The current
482
F. Cruz & J. Bellver
Gynecol Endocrinol, 2014; 30(7): 481–484
Table 1. Described strategies to improve endometrial thickness in women with thin endometrium. Author Demir et al. [9] Shen et al. [10] Acharya et al. [11] Le´de´e-Batalille et al. [12] Cicek et al. [13]
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
Takasaki et al. [14]
Gleicher et al. [16]
Nagori et al. [17] Nagori et al. [17] and present case report (Cruz and Bellver)
Drug therapy
Outcomes
Estradiol hemihydrate (4 mg/day) p.o. from day of hCG injection to 12th week of pregnancy. Estradiol valerate (16 mg/day) p.o. from the 3rd day of menstruation for 9 days, before COS.
No effect on implantation, clinical pregnancy and miscarriage rates or on endometrial thickness Twin pregnancy delivered at 36 weeks in a women with previous implantation failure due to an unresponsive thin endometrium Increase of endometrial thickness in 74% of women
Pentoxifylline (800 mg/day) + vitamin E (1000 IU/day) p.o for 8 months in average before ovulation induction or FET. Pentoxifylline (800 mg/day) + vitamin E (1000 IU/day) p.o. for 6 months and maintained until day of embryo transfer. Vitamin E (400 UI/day) p.o. from 3rd–5th day of the menstrual cycle to the hCG injection day of the COS. Vitamin E (600 mg/day p.o), L-arginine (6 g/day p.o) or sildenafil citrate (100 mg/day intravaginally) from the first day of menstruation to the hCG injection day in natural or COS cycles for ovulation induction or IVF-ET. Granulocyte colony-stimulating factor (30 mU) infused in the uterine cavity 6–12 h before hCG injection, and in unresponsive cases a second infusion after oocyte retrieval. Bone marrow autologous adult stem cells on 2nd day of menstruation after curettage. Increasing doses of oral estradiol valerate from 4 mg/day to 8 mg/day p.o. at least for 4–6 weeks.
Increase of endometrial thickness in 72% of women. Delivery rate of 27% Increase in endometrial thickness but no effect on implantation and ongoing pregnancy rates Increase in endometrial thickness and radial artery resistance index
Increase in endometrial thickness
Increase in endometrial thickness and positive clinical pregnancy in a women with Asherman syndrome Increase in endometrial thickness in combination with bone marrow stem cells (Nagori et al.). No increase in endometrial thickness (present report)
COS, controlled ovarian stimulation; FET, frozen embryuo transfer; hCG, human chorionic gonadotrophin; IVF-ET, in vitro fertilization-embryo transfer; p.o., orally.
Figure 1. First hysteroscopy. Hysteroscopic view of a reduced uterine cavity with a small subseptum, and a thin, atrophic and hyperemic endometrium with a left horn completely covered by fibro-connective adhesions.
experimental role of this test was thoroughly commented to the patient. Considering the patient’s clinical history, and the fact that the endometrium never exceeded 3.5 mm despite high serum estradiol concentrations, fertility options were explained. Given the poor chances of success with her endometrium but the fact that surrogacy is forbidden by Spanish law, the patient opted for ovum donation once the ERA result was known. Single embryo transfer was advised to the patient, but considering the low implantation rate expected a double embryo transfer with a later
Figure 2. Fourth hysteroscopy. Hysteroscopic view of an atrophic endometrium with adhesion re-formation after three previous hysteroscopies and three courses of high dose estrogen therapy.
embryo reduction in the unlikely case of a twin pregnancy was chosen. The previously described 6-week estrogen therapy plan was started, together with 400 mg/12 h pentoxifylline, 400 IU/12 h tocoferol and 50 mg/12 h vaginal syldenafil in the 2 weeks before embryo transfer to try to increase the endometrial thickness. The estradiol concentration achieved was 971 pg/ml, and the endometrial thickness was 3.5 mm. Donated oocytes and spermatozoids were used and two good quality blastocysts were transferred after 5 days of vaginal progesterone administration. Pregnancy was achieved, but unfortunately the gestational sac implanted in the left fallopian tube. The ectopic pregnancy was resolved by
DOI: 10.3109/09513590.2014.900747
laparoscopic salpingotomy and a bilateral proximal tubal ligation. A second ovum donation cycle was attempted with the same endometrial preparation and a double blastocyst transfer was again carried out after achieving a serum estradiol concentration of 1119 pg/ml and an endometrial thickness of 3.5 mm. No pregnancy occurred but three surplus blastocysts were vitrified in this cycle. Finally, two of these blastocysts were transferred after estrogen therapy and 5 days of progesterone administration when a 3.5-mm thick endometrium and 879 pg/ml of serum estradiol concentration were achieved. In all these procedures, the endometrial pattern remained dense and echogenic, and never showed a triple layer pattern. In this third attempt, a single intrauterine pregnancy was detected resulting in the live birth of a healthy girl by the vaginal route at 38 weeks gestation. No pregnancy complications happened.
Healthy live birth in an unresponsive endometrium
483
negative ERA test result in an atrophic endometrium would constitute a reason for uterine surrogation, adoption or abandoning. The diagnosis of the presence of a functional WOI in this echogenic, atrophic endometrium using the ERA test played a key role in the decision to go ahead with the treatment. ERA test is a promising molecular diagnostic tool that, as shown in this case report, may serve as an important decision making factor even in the most difficult cases. However, prospective randomized controlled trials are needed to determine its clinical usefulness. To the best of our knowledge, here we report the thinnest endometrium to date in which a healthy, full term live birth has been achieved in assisted conception [4].
Declaration of interest The authors report no declaration of interest.
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
Discussion Most cancer survivors who received chemotherapy and/or radiotherapy have fertility problems [20–25]. When irreversible ovarian failure occurs ovum donation is considered a definitive solution [26]. Nevertheless, the uterine factor remains an unresolved issue, especially in countries in which uterine surrogacy is forbidden. Total body and pelvic irradiation increases the risk of infertility and pregnancy-related complications due to a reduced uterine volume, impaired uterine distensibility, damaged uterine vasculature and endometrial injury [27–30]. There have been described several approaches to diagnose endometrial receptivity, mainly by pathological analysis, with very little success. Noyes criteria have been abandoned due to their low reproducibility and predictive value [18,19]. So, new diagnostic tools such the ERA test have been recently developed to determine receptivity during WOI at the molecular level [19]. Endometrial biopsy is collected from the uterine fundus using Pipelle catheters from CornierÕ devices (CCD Laboratories, Paris, France), under sterile conditions, either in a natural cycle or in a hormonal replacement therapy (HRT) cycle. The day of the endometrial biopsy in a natural cycle is determined according to the urine or serum detection of the LH peak, whereas in the HRT cycle it is calculated after minimum 10 days of preparation, proper estradiol priming and progesterone impregnation. After the biopsy, the endometrial tissue is transferred to a cryotube containing 1.5 ml of RNALater (QIAGEN, Barcelona, Spain), vigorously shaken for a few seconds, and kept at 4 C or in ice for at least 4 h. The samples are then shipped at room temperature for ERA transcriptomic analysis. Endometrial receptivity array gene expression values are preprocessed, normalized, and the endometrial receptivity status diagnosed by the ERA computational predictor. The ERA test diagnoses the endometrial samples as receptive (R) or not receptive (NR) with an associated diagnostic probability. The NR diagnosed samples, can be classified as pre-receptive or postreceptive. This may allow giving a recommendation for a putative personalized WOI in a particular patient. In our patient, the aim was not to personalize the WOI, but to determinate that endometrial receptivity was present despite the poor endometrial morphology. The ERA test determined that our patient presented a ‘‘receptive’’ endometrium after estradiol priming and 3 days of progesterone administration. The accuracy of the ERA test has been described superior to endometrial histology and the results seem to be reproducible 29–40 months after the first test [18]. The ERA may be useful for determining the best timing for embryo transfer, predicting when implantation is feasible in a particular patient including those with chronic unresponsive atrophic endometrium. Hence, maybe only a
References 1. Revel A. Defective endometrial receptivity. Fertil Steril 2012;97: 1028–32. 2. Zhao J, Zhang Q, Li Y. The effect of endometrial thickness and pattern measured by ultrasonography on pregnancy outcomes during IVF-ET cycles. Reprod Biol Endocrinol 2012;10:100. 3. Traub ML, Van Arsdale A, Pal L, et al. Endometrial thickness, Caucasian ethnicity, and age predict clinical pregnancy following fresh blastocyst embryo transfer: a retrospective cohort. Reprod Biol Endocrinol 2009;22:7–33. 4. Check JH, Cohen R. Live fetus following embryo transfer in a woman with diminished egg reserve whose maximal endometrial thickness was less than 4 mm. Clin Exp Obstet Gynecol 2011;38: 330–2. 5. Amui J, Check JH, Cohen R. Successful twin pregnancy in a donor oocytes recipient despite a maximum endometrial thickness in the late proliferative phase of 4 mm. Clin Exp Obstet Gynecol 2011;38: 328–9. 6. Dix E, Check JH. Successful pregnancies following embryo transfer despite very thin late proliferative endometrium. Clin Exp Obstet Gynecol 2010;37:15–6. 7. Toth B, Wu¨rfel W, Germeyer A, et al. Disorders of implantation – are there diagnostic and therapeutic options? J Reprod Immunol 2011;90:117–23. 8. Shufaro Y, Simon A, Laufer N, Fatum M. Thin unresponsive endometrium: a possible complication of surgical curettage compromising ART outcome. J Assist Reprod Genet 2008;25:421–5. 9. Demir B, Dilbaz S, Cinar O, et al. Estradiol supplementation in intracytoplasmic sperm injection cycles with thin endometrium. Gynecol Endocrinol 2013;29:42–5. 10. Shen MS, Wang CW, Chen CH, Tzeng CR. New horizon on successful management for a woman with repeated implantation failure due to unresponsive thin endometrium: use of extended estrogen supplementation. J Obstet Gynaecol Res 2013;39:1092–4. 11. Acharya S, Yasmin E, Balen AH. The use of a combination of pentoxifylline and tocopherol in women with a thin endometrium undergoing assisted conception therapies – a report of 20 cases. Hum Fertil (Camb) 2009;12:198–203. 12. Le´de´e-Bataille N, Olivennes F, Lefaix JL, et al. Combined treatment by pentoxifylline and tocopherol for recipient women with a thin endometrium enrolled in an oocyte donation programme. Hum Reprod 2002;17:1249–53. 13. Cicek N, Eryilmaz OG, Sarikaya E, et al. Vitamin E effect on controlled ovarian stimulation of unexplained infertile women. J Assist Reprod Genet 2012;29:325–8. 14. Takasaki A, Tamura H, Miwa I, et al. Endometrial growth and uterine blood flow: a pilot study for improving endometrial thickness in patients with a thin endometrium. Fertil Steril 2010; 93:1851–8. 15. Senturk LM, Erel CT. Thin endometrium in assisted reproductive technology. Curr Opin Obstet Gynecol 2008;20:221–8. 16. Gleicher N, Kim A, Michaeli T, et al. A pilot cohort study of granulocyte colony-stimulating factor in the treatment of unresponsive thin endometrium resistant to standard therapies. Hum Reprod 2013;28:172–7.
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17. Nagori CB, Panchal SY, Patel H. Endometrial regeneration using autologous adult stem cells followed by conception by in vitro fertilization in a patient of severe Asherman’s syndrome. J Hum Reprod Sci 2011;4:43–8. 18. Dı´az-Gimeno P, Ruiz-Alonso M, Blesa D, et al. The accuracy and reproducibility of the endometrial receptivity array is superior to histological dating as diagnostic method for the endometrial factor. Fertil Steril 2013;99:508–17. 19. Dı´az-Gimeno P, Horcajadas JA, Martı´nez-Conejero JA, et al. A genomic diagnostic tool for human endometrial receptivity based on the transcriptomic signature. Fertil Steril 2011;95:50–60. 20. Larsen EC, Schmiegelow K, Rechnitzer C, et al. Radiotherapy at a young age reduces uterine volume of childhood cancer survivors. Acta Obstet Gynecol Scand 2004;83:96–102. 21. Critchley HO, Wallace WH. Impact of cancer treatment on uterine function. J Natl Cancer Inst Monogr 2005;34:64–8. 22. Revelli A, Rovei V, Racca C, et al. Impact of oncostatic treatments for childhood malignancies (radiotherapy and chemotherapy) on uterine competence to pregnancy. Obstet Gynecol Surv 2007;62: 803–11. 23. Sudour H, Chastagner P, Claude L, et al. Fertility and pregnancy outcome after abdominal irradiation that included or excluded the
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24. 25. 26.
27. 28. 29. 30.
pelvis in childhood tumor survivors. Int J Radiat Oncol Biol Phys 2010;76:867–73. Hudson MM. Reproductive outcomes for survivors of childhood cancer. Obstet Gynecol. 2010;116:1171–83. Watanabe T, Matsubara S, Saito Y, et al. Pregnant woman with an extremely small uterus due to pelvic irradiation in childhood. J Obstet Gynaecol Res 2012;38:559–61. Vernaeve V, Bodri D, Colodro´n M, et al. Endometrial receptivity after oocyte donation in recipients with a history of chemotherapy and/or radiotherapy. Hum Reprod. 2007;22: 2863–7. Urbano MT, Tait DM. Can the irradiated uterus sustain a pregnancy? A literature review. Clin Oncol (R Coll Radiol) 2004; 16:24–8. Letur-Ko¨nirsch H, Lefaix JL, Delanian S. Uterus after irradiation. Gynecol Obstet Fertil 2005;33:605–9. Ferreri AJ, Verona C, Bolognesi A, et al. Successful pregnancy after chemo-immuno-radiation therapy for aggressive lymphoma of the uterus. Br J Haematol 2008;142:141–3. Wo JY, Viswanathan AN. Impact of radiotherapy on fertility, pregnancy, and neonatal outcomes in female cancer patients. Int J Radiat Oncol Biol Phys 2009;73:1304–12.
EMBRYO TRANSFER IN THIN ENDOMETRIUM
Live birth after embryo transfer in an unresponsive thin endometrium Fa´bio Cruz1 and Jose´ Bellver1,2,3 1
Instituto Valenciano de Infertilidad, Valencia, Spain, 2Fundacio´n IVI, Instituto Universitario IVI, University of Valencia, Valencia, Spain, and Department of Pediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
3
Abstract
Keywords
A healthy term livebirth in a 35-year-old woman with ovarian failure, hypoplastic uterus and atrophic endometrium after cancer treatment with chemotherapy and radiotherapy was achieved by ovum donation. The detection of a receptive endometrium using a new diagnostic tool of endometrial receptivity encouraged the medical team to carry on with this poor prognosis case. To the best of our knowledge, here we report the thinnest endometrium to date in which a healthy, full term live birth has been described in assisted conception.
Atrophic endometrium, endometrial receptivity, endometrial receptivity array, live birth, uterine radiotherapy
Introduction Endometrial receptivity is essential for successful embryo implantation [1]. An endometrial thickness 7 mm has been related to better implantation rates [2,3]. Nevertheless, pregnancies and live births have been recorded with thinner endometria [4–6], and pregnancy failures also occur in morphologically normal endometria [7]. Unresponsive thin endometrium is usually related to previous vigorous curettages, infection, Asherman’s syndrome or uterine irradiation [8]. The reproductive outcome is consistently poor in this situation. In recent years, several strategies have been suggested to improve the endometrial thickness and quality, such as administration of extended or high estrogen therapy [9,10], pentoxyfilline [11,12], tocoferol [11–13], arginine [14], sildenafil citrate [15] or even intrauterine perfusion with granulocyte colony-stimulating factor [16] and autologous uterine stem cell therapy [17] (Table 1), with poor, unknown or inconsistent results. Adoption or surrogacy is chosen in severe cases, but social, economic or legal restrictions make these options not frequently available.
Case report A 35-year-old woman with a 2-year iatrogenic ovarian failure came to our center seeking reproductive advice. As a consequence of M4 acute myeloblastic leukemia, she had undergone chemotherapy and radiotherapy prior to bone marrow transplantation consisting of induction chemotherapy with idarubicin and cytarabine, followed by a conditioning regimen which included anti-thymocyte globulin, cyclophosphamide and total body irradiation on two consecutive days (6 Gy/day). She suffered
Address for correspondence: Jose´ Bellver, M.D., Instituto Valenciano de Infertilidad, Plaza de la Policı´a Local, 3, 46015, Valencia, Spain. Tel: +34 963050900. Fax: +34 963050999. E-mail: [email protected]
History Received 6 October 2013 Revised 10 February 2014 Accepted 27 February 2014 Published online 20 March 2014
from two graft-versus-host diseases treated with corticosteroids and immunosuppressants, and finally went into remission. At her first visit, the ultrasound examination showed atrophic ovaries and a hypoplastic uterus (5.5 cm 2.7 cm 3.2 cm) with a very thin endometrium. Oral estrogen therapy with 6 mg/day of estradiol valerate (Progynova, Bayer, Spain) was given for 20 days to assess the endometrial response, but the maximum endometrial size achieved was of only 3 mm. Afterwards, two more courses of estradiol valerate with increasing doses were given for 6 weeks (first week: 2 mg/day; second week: 4 mg/day; third week: 6mg/day, and 8 mg/day from the fourth week), and 800 mg/day of vaginal micronized progesterone (Progeffik, Laboratorios EFFIK, Spain) were added in the last 2 weeks to induce menstruation. In both courses, serum estradiol concentrations achieved were 636 and 1092 pg/ml, respectively, but the endometrium never became thicker than 3 mm and showed a dense echogenic pattern. Hysteroscopy showed a short cervical channel, a hypoplastic uterine cavity with a small subseptum, and a thin, atrophic and hyperemic endometrium with a left horn completely covered by fibro-connective adhesions (Figure 1) which relapsed despite three hysteroscopic surgeries and administration of high-dose estrogen therapy between them. Pathological examination of random biopsies showed some proliferative areas. In a fourth hysteroscopy (Figure 2), after estrogen therapy and 3 days of 800 mg/day of micronized progesterone, an endometrial biopsy was taken showing minimal secretory changes and a ‘‘receptive’’ endometrium according to the Endometrial Receptivity Array (ERA) test. The ERA consists of a newly developed customized array containing 238 genes expressed at the different stages of the endometrial cycle, coupled to a computational predictor designed to identify the receptivity status of an endometrial sample and to diagnose the patient’s window of implantation (WOI) regardless of the histological appearance of the sample [18,19]. The ERA test classifies the endometrial samples as receptive or not receptive with an associated diagnostic probability. The current
482
F. Cruz & J. Bellver
Gynecol Endocrinol, 2014; 30(7): 481–484
Table 1. Described strategies to improve endometrial thickness in women with thin endometrium. Author Demir et al. [9] Shen et al. [10] Acharya et al. [11] Le´de´e-Batalille et al. [12] Cicek et al. [13]
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
Takasaki et al. [14]
Gleicher et al. [16]
Nagori et al. [17] Nagori et al. [17] and present case report (Cruz and Bellver)
Drug therapy
Outcomes
Estradiol hemihydrate (4 mg/day) p.o. from day of hCG injection to 12th week of pregnancy. Estradiol valerate (16 mg/day) p.o. from the 3rd day of menstruation for 9 days, before COS.
No effect on implantation, clinical pregnancy and miscarriage rates or on endometrial thickness Twin pregnancy delivered at 36 weeks in a women with previous implantation failure due to an unresponsive thin endometrium Increase of endometrial thickness in 74% of women
Pentoxifylline (800 mg/day) + vitamin E (1000 IU/day) p.o for 8 months in average before ovulation induction or FET. Pentoxifylline (800 mg/day) + vitamin E (1000 IU/day) p.o. for 6 months and maintained until day of embryo transfer. Vitamin E (400 UI/day) p.o. from 3rd–5th day of the menstrual cycle to the hCG injection day of the COS. Vitamin E (600 mg/day p.o), L-arginine (6 g/day p.o) or sildenafil citrate (100 mg/day intravaginally) from the first day of menstruation to the hCG injection day in natural or COS cycles for ovulation induction or IVF-ET. Granulocyte colony-stimulating factor (30 mU) infused in the uterine cavity 6–12 h before hCG injection, and in unresponsive cases a second infusion after oocyte retrieval. Bone marrow autologous adult stem cells on 2nd day of menstruation after curettage. Increasing doses of oral estradiol valerate from 4 mg/day to 8 mg/day p.o. at least for 4–6 weeks.
Increase of endometrial thickness in 72% of women. Delivery rate of 27% Increase in endometrial thickness but no effect on implantation and ongoing pregnancy rates Increase in endometrial thickness and radial artery resistance index
Increase in endometrial thickness
Increase in endometrial thickness and positive clinical pregnancy in a women with Asherman syndrome Increase in endometrial thickness in combination with bone marrow stem cells (Nagori et al.). No increase in endometrial thickness (present report)
COS, controlled ovarian stimulation; FET, frozen embryuo transfer; hCG, human chorionic gonadotrophin; IVF-ET, in vitro fertilization-embryo transfer; p.o., orally.
Figure 1. First hysteroscopy. Hysteroscopic view of a reduced uterine cavity with a small subseptum, and a thin, atrophic and hyperemic endometrium with a left horn completely covered by fibro-connective adhesions.
experimental role of this test was thoroughly commented to the patient. Considering the patient’s clinical history, and the fact that the endometrium never exceeded 3.5 mm despite high serum estradiol concentrations, fertility options were explained. Given the poor chances of success with her endometrium but the fact that surrogacy is forbidden by Spanish law, the patient opted for ovum donation once the ERA result was known. Single embryo transfer was advised to the patient, but considering the low implantation rate expected a double embryo transfer with a later
Figure 2. Fourth hysteroscopy. Hysteroscopic view of an atrophic endometrium with adhesion re-formation after three previous hysteroscopies and three courses of high dose estrogen therapy.
embryo reduction in the unlikely case of a twin pregnancy was chosen. The previously described 6-week estrogen therapy plan was started, together with 400 mg/12 h pentoxifylline, 400 IU/12 h tocoferol and 50 mg/12 h vaginal syldenafil in the 2 weeks before embryo transfer to try to increase the endometrial thickness. The estradiol concentration achieved was 971 pg/ml, and the endometrial thickness was 3.5 mm. Donated oocytes and spermatozoids were used and two good quality blastocysts were transferred after 5 days of vaginal progesterone administration. Pregnancy was achieved, but unfortunately the gestational sac implanted in the left fallopian tube. The ectopic pregnancy was resolved by
DOI: 10.3109/09513590.2014.900747
laparoscopic salpingotomy and a bilateral proximal tubal ligation. A second ovum donation cycle was attempted with the same endometrial preparation and a double blastocyst transfer was again carried out after achieving a serum estradiol concentration of 1119 pg/ml and an endometrial thickness of 3.5 mm. No pregnancy occurred but three surplus blastocysts were vitrified in this cycle. Finally, two of these blastocysts were transferred after estrogen therapy and 5 days of progesterone administration when a 3.5-mm thick endometrium and 879 pg/ml of serum estradiol concentration were achieved. In all these procedures, the endometrial pattern remained dense and echogenic, and never showed a triple layer pattern. In this third attempt, a single intrauterine pregnancy was detected resulting in the live birth of a healthy girl by the vaginal route at 38 weeks gestation. No pregnancy complications happened.
Healthy live birth in an unresponsive endometrium
483
negative ERA test result in an atrophic endometrium would constitute a reason for uterine surrogation, adoption or abandoning. The diagnosis of the presence of a functional WOI in this echogenic, atrophic endometrium using the ERA test played a key role in the decision to go ahead with the treatment. ERA test is a promising molecular diagnostic tool that, as shown in this case report, may serve as an important decision making factor even in the most difficult cases. However, prospective randomized controlled trials are needed to determine its clinical usefulness. To the best of our knowledge, here we report the thinnest endometrium to date in which a healthy, full term live birth has been achieved in assisted conception [4].
Declaration of interest The authors report no declaration of interest.
Gynecol Endocrinol Downloaded from informahealthcare.com by Nyu Medical Center on 10/19/14 For personal use only.
Discussion Most cancer survivors who received chemotherapy and/or radiotherapy have fertility problems [20–25]. When irreversible ovarian failure occurs ovum donation is considered a definitive solution [26]. Nevertheless, the uterine factor remains an unresolved issue, especially in countries in which uterine surrogacy is forbidden. Total body and pelvic irradiation increases the risk of infertility and pregnancy-related complications due to a reduced uterine volume, impaired uterine distensibility, damaged uterine vasculature and endometrial injury [27–30]. There have been described several approaches to diagnose endometrial receptivity, mainly by pathological analysis, with very little success. Noyes criteria have been abandoned due to their low reproducibility and predictive value [18,19]. So, new diagnostic tools such the ERA test have been recently developed to determine receptivity during WOI at the molecular level [19]. Endometrial biopsy is collected from the uterine fundus using Pipelle catheters from CornierÕ devices (CCD Laboratories, Paris, France), under sterile conditions, either in a natural cycle or in a hormonal replacement therapy (HRT) cycle. The day of the endometrial biopsy in a natural cycle is determined according to the urine or serum detection of the LH peak, whereas in the HRT cycle it is calculated after minimum 10 days of preparation, proper estradiol priming and progesterone impregnation. After the biopsy, the endometrial tissue is transferred to a cryotube containing 1.5 ml of RNALater (QIAGEN, Barcelona, Spain), vigorously shaken for a few seconds, and kept at 4 C or in ice for at least 4 h. The samples are then shipped at room temperature for ERA transcriptomic analysis. Endometrial receptivity array gene expression values are preprocessed, normalized, and the endometrial receptivity status diagnosed by the ERA computational predictor. The ERA test diagnoses the endometrial samples as receptive (R) or not receptive (NR) with an associated diagnostic probability. The NR diagnosed samples, can be classified as pre-receptive or postreceptive. This may allow giving a recommendation for a putative personalized WOI in a particular patient. In our patient, the aim was not to personalize the WOI, but to determinate that endometrial receptivity was present despite the poor endometrial morphology. The ERA test determined that our patient presented a ‘‘receptive’’ endometrium after estradiol priming and 3 days of progesterone administration. The accuracy of the ERA test has been described superior to endometrial histology and the results seem to be reproducible 29–40 months after the first test [18]. The ERA may be useful for determining the best timing for embryo transfer, predicting when implantation is feasible in a particular patient including those with chronic unresponsive atrophic endometrium. Hence, maybe only a
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