Endometrial Scratching...is it as bad as the name suggests?!?

[GlummyMummy]

This has been recommended to me by my clinic as a possible way of increasing my lining which was disappointingly thin last time round IVF.

I am just a bit concerned as one reason for thin lining is Ashermans which is scarring to the womb, so surely scratching the womb would lead to Ashermans?!?! Also, as it's a new thing at my clinic, they were unable to give me any information on the long term side effects of this - any ideas? Is it worth having it done?

I'm a thin lining-er and my consultant did an endometrial biopsy, which he said is like a turbo endometrial scratch, while he was doing my hysteroscopy

Prof Quenby and Brosens latest research into implantation failure and recurrent miscarriage suggest the endometrial scratch and the inflammation it generates can make a huge difference, so I'm very much hoping this will help with my upcoming FET

The benefits I am told last for approximately 3 cycles

My consultant didn't suggest it would do anything to thicken the lining - it just helps to generate inflammation which can help support the decidualisation process. I don't think it can necessarily do much to help in the proliferative phase which is where the lining thickens up

Hi ladies. I have persistent thin lining. Fresh IVF was a freeze all due to thin lining (4.2mm). Then 5 attempts at FET with various drug concoctions were all abandoned as thickest lining got to was 5.4mm, but would always decrease to 4.7mm straight after ovulation. I went for private opinion with Prof Quenby and Brosens. They had theory that 2 scratches in 2 consecutive cycles would make the lining the best it could ever be. After 1 scratch my lining was 6.3mm. I was so excited as at this stage previously it had always been 4.7mm. Second scratch and it was 6.5mm after ovulation, so we finally went ahead with our FET. I know 6.5mm is still thin but it's the best I've ever had and taken years to get there. I'm now 3dp5dt so yet to see if it's worked! Other than that my lining looked great quality.
I don't know about the long term risks, but the evidence for increasing implantation is there and seemingly there is emerging evidence for it assisting with thickness too. I'm willing to take any risks that may arise in the future if it gives me chance of a bfp. Without any increase in lining we were looking at surrogacy. A terrifying thought. I feel the Quenby/ Brosens scratch has given us a golden ticket (regardless of the outcome)!
It should be noted that the Quenby / Brosens scratch is incredible! I'd had 2 prior to that at my local NHS clinic. Those scratches were just a 'nick', lasted a fraction of the time and made no difference whatever to the lining thickness.

I got pg after a scratch during an ivf cycle. So do a few other ladies I know. Do it!

It's a fair bit uncomfy but literally takes 10 seconds so not unbearable.

Funkymonk just wanted to wish you the very best of luck with this cycle

I've had lining problems, although nothing yet to what you've had to go through (and the extended exposure to oestrogen over 2 months while I was pregnant, before I miscarried due to crap lining, appear to have unregulated the oestrogen receptors in my endometrium as my lining grew all by itself in my fresh cycle, couldn't believe it!). We've done freeze all in order to do PGS and I'm hoping that my lining will respond for our upcoming FET

Out of interest what strategies did you try previous to the scratch? Been reading up on tamoxifen, viagra, extended trental + vitamin E and G-CSF washes, in case my lining goes on strike.

Really delighted to hear the Profs have been able to help. The Coventry clinic are just brilliant!!

Hi Banana! Coventry have really been ace! So sorry to hear about your mc. I've had 3 previous losses, deemed now to be due to thin lining. We tried a completely natural cycle (max 5.4mm), a cycle with quadruple oestrogen (tablets, pessaries and patches - got to 5.4mm), a cycle with viagra (max 5.4mm), a medicated cycle with downregging first and then building up with oestrogen (max 5.4mm). The plan with the downregged cycle was to continue oestrogen priming until lining got to desired thickness. However after it reached 5.4mm, despite continuing the meds it decreased to 3.9mm
After my own research, about 10months ago I started high doses of vitamin E and L'arginine. Although these didn't have the desired effect on thickening lining, it has made a fantastic difference to the quality of the lining, that even I can see on the dildocam scans. Also my ovulation has always been day 17 with a 8-10 day luteal phase and it is now always day 14 with a 11-14 day luteal phase.
I had read about the GCSF washes, the tamoxifen and pentoxyfillin (spelling?) but Coventry said to try the 2 scratches in a row. If this doesnt work then I'll go back to them and ask about these other things. They looked at my nk cells too and I am now also on prednisolone. I'm not feeling hopeful, but then I think infertility does that to you after disappointment after disappointment.

When do you hope to get started? Were you taking progesterone alongside the oestrogen during your last pregnancy? Do you know what your lining usually is?

Glummy sorry to hijack your thread

really interesting ladies, sounds like overwhelming evidence in favour of the scratch!! I think I just couldn't understand how scarring (Ashermans) can cause implantation/lining issues, yet scratching can't!! All sounds the same to me and a bit evasive!! Are there any long term side effects of the endo scratch? Maybe they don't know yet as it's a fairly new thing.

Fingers crossed for you Funkymonk! That's interesting about the Vit E and L'arginine - I'd read about those too. It's so frustrating when you have good embryos but lining crap!

Ah funkymonk you've had such a tough time of it, I really really hope this is the one for you. I have my fingers and toes tightly crossed for you

Since coming off the pill for n my natural cycles I ovulated but didn't really have a period at all. A bit of brown/black spotting and that was it.

Complete absence of any cervical mucus, the clearblue dual hormone OPK jumping straight from low to peak and scanty periods suggested some kind of oestrogen issue and therefore I suspected thin lining

In my clomid cycle the lining didn't get above 4.6mm but we thought that might have been the Clomid

During my first IVF cycle my lining got to 7.2mm before trigger but then thinned to 6.4mm at EC. We had to freeze all due to other issues in any case.

In the natural cycle immediately after, I decided to throw every natural trick in the book to see what my lining would do in a natural cycle. Vitamin E, l-arginine, aspirin, vaginal viagra, acupuncture, heat packs, red raspberry leaf tea, all that jazz. Went to get a scan and was about to ovulate but lining was 4.2mm and not triple line. Dr checked my uterine blood flow and it was fantastic. So not surprising none of those tricks had worked because my problem wasn't blood flow. He said the issue was that the oestrogen receptors in my endometrium (antennae, he called them) were sleepy, probably from long term use of the pill, and he hoped that the cumulative effect of oestrogen expose would wake them up

We decided to do another fresh cycle because we only had a very few eggs and with my low AMH we wanted to bank embryos while we could. That was in Jan. My lining was an OK 7mm before trigger but thinned to 5.5mm at EC

I'd started progynova the day of trigger and came in for a lining scan on day 4, when we would decide if we would transfer, or freeze all. My lining had thickened up to 8.5mm so we decided to transfer. However it was already compacting under the influence of progesterone so my hunch is the quality wasn't great. But amazingly, the embryo implanted, Dr was thrilled that the endometrium was appropriately thickened at the 7w scan, but sadly at the 10w scan we discovered I'd had a MMC. Tissue testing showed the baby was chromosomally normal

We think that although the lining thickened up, the top soil was OK but the bottom soil was crap. The only bleed I'd had was after my first IVF cycle in Oct. Thereafter I ovulated, started down regging for an attempt at doing LP for IVF #2 (with the intention that we could control my lining better on long protocol), which got cancelled because I ovulated whilst on buserelin and failed for down reg, went on the pill for a month. But when I came off the pill to try another crack at IVF #2, I didn't have a withdrawal bleed. Just a bit of black spotting.

So we think whatever lining had built up between October and January just never got a proper clear out. So when the lining thickened up, it was probably on crap foundations. Given all the new research from Coventry about the importance of menstruation to regeneration of the lining, as a key factor in recurrent miscarriage, it makes sense

This cycle, IVF #3, incredibly, my lining grew to 11.1mm all by itself!!! I couldn't believe it. So the 2 months of oestrogen exposure while I was pregnant did indeed seem to have helped to wake up my lining and make it more responsive.

Dr said we won't put anything back until he's confident in the quality of the endometrium. He wants me to menstruate properly to have a decent clear out, as he saw there was still some old blood from the miscarriage when he did a hysteroscopy - and I never had a bleed post ERPC.

So I'm nervously waiting for a period, and hoping for Niagara Falls. 11mm has go somewhere, surely??!! Due today but so far just black gunge (sorry TMI) which is how all my 'periods' have started, but never went any further. Panicking my period will go on strike and the lining won't shed (yes, the IVF crazy has set in)

Trying to encourage a bleed with a heat pack strapped to my belly, raspberry leaf tea, wearing white knickers to invoke the law of sod, and this evening will deploy a hot bath and an orgasm to try and get things moving

Ironic for TTC to be absolutely desperate for a period to turn up!

Gosh that was an epic ramble. Sorry for hijacking your thread Glummy with lining chat!

Oh and if my period does actually start and we can crack on with trying a FET we are throwing the kitchen sink at it

-PGS tested embryo [tick]
-endometrial biopsy [tick]
-oestrogen pills / patches
-vitamin E and L-arginine
-clexane
-aspirin
-prednisolone
-intralipids
-Lubion (injectable progesterone)
-Cyclogest

And cross everything and hope for the best!

bananafish - what a time you have had!! But you are obviously doing all the right things!

Have contacted my Dr to ask about long term effects of the scratch, so we shall see!

I had an endometrial scratch for four IVF cycles (3 natural IVF cycles and 1 donor egg cycle). I got pregnant on the donor egg cycle. The first time they did a biopsy (I think because they thought they might as well).

As mentioned above, I didn't think it necessarily helps your lining to thicken? I thought it helped implantation in some 'mysterious' way. My lining was always fine anyway.

I am not aware of any side effects. But then I didn't have any scarring to the womb so I can understand your concern there. I do suggest you look into that further.

I found it a bit uncomfortable, at least partly because I was busting for a wee and the bed was tilted so my head was down. But nothing unmanageable.

Good luck.

I have had two failed cracks at ivf, this time round I had the scratch and I'm nearly 10 weeks pregnant. Never had any issues with lining that I'm aware of though. It wasn't fun but it wasn't that bad, slightly worse than a smear.

thanks both! I'm not too sure why it's been suggested to me as lining was my main issue last time, but suppose it can't hurt to try! I was just worried that if it's not to help thicken lining it might have the reverse effect and possibly harm the lining in some way? Maybe just over worrying here.....

Congratulations hellotreehellosky - hope you are keeping well. Was the scratch the only thing you did differently this time around?

Basically it stimulates a positive immune response that increases receptivity

The mechanism by which endometrial biopsy gains its favorable effect on IVF pregnancy outcome was recently suggested by our studies showing that the biopsy induced an increase in the levels of different pro-inflammatory cytokines and in the abundance of specific immune cells in the endometrium. These pro-inflammatory cytokines were previously detected in the endometrium during the window of implantation and are possibly involved in the recruitment of the immune cells to the tissue. These immune cells secrete their own cytokines and growth factors that, in turn, induce cell proliferation and differentiation as well as vascularization. Most importantly, a positive correlation between the biopsy-induced pro-inflammatory cytokine and immune cell levels and pregnancy rate after IVF treatment was observed, clearly supporting our suggested mechanism.

http://www.ivf-worldwide.com/ivf-worldwide-blog/endometrial-biopsy-improves-implantation-pregnancy-outcome.html

A 'normal' endometrial scratch is done to improve implantation as per my previous post

It's not done with the specific aim, nor is it expected to improve the thickness of the endometrium, in the majority of cases. It is designed to increase the receptivity of the endometrium - but isn't likely to thicken it (nor should it damage it either)

The treatment funky has had with Coventry is more specific to her individual case, using sequential scratches to support otherwise completely treatment resistant lining

The scratch is completely different from ashermans - that's scraping into the basal layers of the endometrium causing adhesions to form. The scratch is a small and very localised biopsy which triggers a temporary inflammatory response

Banana 11mm is awesome! I agree, you must get a Niagara Falls after that! Gosh, you've really been through the mill too.
I forgot to add that I've also been on low dose aspirin for about 12 months now. I have factor v leiden thrombophilia apparently, which was diagnosed after recurrent mc tests, so if I ever get a bfp again then I'll be on heparin injections for the duration of the pregnancy.

glummy I think banana makes a good point with her last post. I had been thinking about that too. The endo scratch is gently scratching the uterus lining. The d&c procedure that can cause Ashermans, would surely be more vigorous (therefore possibly leading to adhesions) as the 'products remaining from conception' need to be completely removed, at which stage the embryo would be well implanted into the uterine wall?? I expect there are no studies on the long term risk of the endoscratch as the procedure is so new. Also like most areas of fertility, research is very minimal and half the time is contraindicating.

Would you both be interested if I set up a thread on 'lining issues and IVF' or something along those lines? Then we can follow journeys, get tips etc. Hopefully it would attract some other bods too.

Banana, are you on NHS cycle and paying for private additions for your treatment? Anyway, I have about 2 weeks of vagifem oestrogen pessaries which you are welcome too. Probably a few patches too. Message me if you want them and I can send them out.

Thanks Glummy. Last year I had mild ivf, one fresh and one frozen transfer, two bfns. This time round scratch and full ivf, but still short protocol and the lowest dose and ended up with the same number of embryos. One fresh transfer and I got my bfp. It was our last go so we thought we'd throw the kitchen sink, within reason, and all the clinic could suggest to improve implantation chances was the scratch. I'll never know if this one would have stuck anyway I guess.

Sorry hellotree I missed your post somehow. Congrats to you on your recent bfp. You must be delighted, especially it was going to be your last attempt. I've been ttc for almost 4 years and I've certainly read/heard a lot of women swear that the scratch made the difference for them. I wonder if the effects are long lasting? E.g if I get BFN this cycle then can I do a FET next month or would I need a scratch again?

I had four natural/ mild IVF cycles. I had an MC from the first cycle, no success on the next two, and tried a scratch with the fourth from which I had a lovely little girl. I have no idea if the scratch made the difference for us but it wasn't painful and I'd definitely give it a go if we were ever to go for another. I do wonder if implantation was our issue. I bled for three weeks in the first tri and delivered at 34 weeks by planned CS as she was struggling due to poor blood flow through the placenta.

I should add a "good luck" and firm handhold for those still going through the shitfest that is long term ttc and fertility treatment.

bananafish - that makes sense, thanks for clearing that up...I do wonder if the "clean up" they did after my post-partum hemorrhage may have caused some scarring which impacted on my 2nd IVF attempt.

Kind of baffled why I've been recommended the scratch then if it's not really for lining issues. I've only had one failed ivf and no miscarriages. Not even sure if the failed one last time was due to implantation problem or abnormality with the embryo.

Funkymonk - you're right - prob no long term evidence, think my clinic has only just started doing scratches (bit behind everyone else!!)

Thanks funky I am no expert but I've read they are good for three months.

euro that's interesting, we've had secondary infertility and my DS was prem due to placenta problems. I've also mc at 12 weeks. Our diagnosed problem is male factor but I wonder if we have implanting problems too.

funkymonk would LOVE a thread on lining issues - I often feel a bit of an outsider, as seems that most people seem to have no problems at all with lining, so I think would be fab to be able to support each other, swap tips - and as you say, hopefully others will join in. I know there are a couple of other posters on other threads with lining issues, so I’m sure there are a few more out there

I very much hope that you will be the success story beacon with this FET, thinking of you and hoping you’re surviving the 2ww

Sadly I’m not NHS, fully self funding. We rushed to IVF very quickly due to tests all showing severe diminished ovarian reserve, and hurtling towards premature ovarian failure - hence we hadn’t been TTC long enough to be eligible. But thank you for the very kind offer - very thoughtful of you!

Glad you’ve had the thrombophilia diagnosed & treated accordingly. I had all those tests done just before my second cycle (ie before the m/c) - they all came back clear, but we’ll be treating empirically with aspirin and Clexane for the upcoming FET as part of an immunes protocol. Dr had recommended starting aspirin the day after ET (alongside Clexane) - but will ask if there’s any merit in starting it earlier, as additional lining support before ET

BTW I was told the benefits of the scratch lasted for approx. 3 cycles - I had my hysteroscopy 2 weeks prior to beginning my fresh cycle, and IF the FET goes ahead next cycle, we do not plan to do another scratch. If we can’t proceed this month, will ask about repeating it

glummy def agree with funky on Ashermans. Was obv a big concern of mine, so discussed it with the consultant before the ERPC. Because it was the same consultant who’d treated me through both cycles, he was very very aware of my lining issues, and he said he would be extra careful not to scrape, and he’d never had a case of Ashermans yet. He explained that ultrasound guidance is relatively limited - you get a general picture but can’t see every tiny fragment of tissue. And so to ensure that everything is properly removed, Drs basically have to ‘scrape the bowl clean’ relatively vigorously, which can then risk adhesions

Because my Dr was so careful not to scrape, the down side was that my hCG levels were still pretty high 6-weeks post ERPC - ultrasound was showing no evidence of retained products, but obv the hCG was coming from somewhere. He went in with a camera for a closer look; hysteroscopy showed a teeny fragment of tissue left behind - which he was able to very delicately remove. Although the ‘softly softly’ approach didn’t get everything out first time, it was far more preferable than risking Ashermans. Was pleased to have had the hysto in any case, as it meant he could give the uterine environment a once over to check what state it was in post mc/ERPC, before we put anything else back.

Interestingly, re: the endometrial biopsy and long term, effects, I remember reading in the new book by Prof Robert Winston, where he’s pretty scathing about most additional interventions being a total con, he was v v pro the scratch, saying it was similar to something they used to do years ago. Will go back and have another look & double check what he says

hellotree many congrats, wishing you all the very best for a happy and healthy pregnancy

euro congrats on your DD

AFM, it’s 18 days post EC and my period is completely AWOL. I’m terrified as I don’t understand what could have gone wrong that I’ve not yet had a bleed. With a freeze all cycle I’ve not been taking any progesterone, so if anything I should have got my period earlier rather than later. It arrived 12 days after EC after my first IVF cycle, which was freeze all - which the Dr said was completely normal, as the retrieval process disrupts progesterone production (hence why we have to take Cyclogest for a fresh transfer) and it was normal to have a shorter luteal phase

I’m really nervous as to what’s going on. I didn’t menstruate before because I didn’t have any real lining to shed - this cycle I had 11mm, so where’s it gone?! Dr said it’s imperative I have a proper bleed as I haven’t had a clearout since the miscarriage. I’m supposed to call up when my period arrives so we can arrange baseline scan to get cracking with a FET: going to have to call to say, OK, what do we do if it’s gone on strike?

Bananafish - I think I will have the scratch done as sounds like it can't do any harm and may do some good! It's hard when something is new and there is no long term evidence...I always worry about what all these things are doing to our bodies!

As a total aside, do you happen to know when I should stop taking all the supplements I am on if going onto long protocol....is it ok to continue with Vit E, ubiquinol etc during IVF?