Experiences with endometrial biopsy

[kennetrose]

What are people's experiences with this test? Why did you have it, what were the results, and did that have any impact/effect on treatment and success?

We've started pursuing private treatment and because we're paying for the ovulation induction and cycle monitoring, I'm in a 'kitchen sink' mindset where I just want to rule everything out. I had chlamydia and other infections in my early 20s and although my tubes are clear I'm still concerned there may be lingering effects, e.g. endometritis.

I had an ERA EMMA ALICE after 2 unsuccessful transfers, this was because I pushed for it, my clinic normally do the ERA much later and they had never done the EMMA ALICE before. I have recurrent implantation failure, despite regular cycles I'd never had a BFP and I has high rates of euploid embryos, so it made no sense why they never implant. I would also recommend it for anyone with DOR who is due to have a FET as the embryos are so precious and they can't afford to do trial and error with them.

The ALICE looks for the bacteria that cause chronic endometritis, I didn't have any of them luckily. The EMMA looks at the percentages of good bacteria- lactobacillus and dysbiotic bacteria. Lactobacillus needs to be >90% for good outcomes. I had shocking results- 0.00% lactobacillus. I've just finish my 7 day course of antibiotics and I'll now be on vaginal probiotics for 10 days. If anyone is considering the ERA please push for the EMMA ALICE too.

The ERA looks at the genes that are activated in the endometrium, for people having medicated FET it tells them if they're endometrium is receptive at the time of the planned transfer. I'm prereceptive, so I'll be on progesterone for longer in my next FET.

If you're not having a medicated FET then you may not need to ERA. If you're worried about the microflora then it mig be be worth pursuing the EMMA ALICE.

Thanks @Gardenlady543! My clinic does it as n endometrial trio so ERA, EMMA and ALICE as one. It does feel a bit silly pushing for an ERA but I would like the EMMA and ALICE. Like I said I have a history of infections and although they have long been treated I still worry given I haven’t ever had a BFP.

I do wonder why it’s not a more routine test? Is it just the discomfort or does it show a lot of things that don’t definitively cause problems so it’s better to see if they cause problems before treating?

Hope this does the trick for you and your next FET is the one.

@kennetrose I have no idea why it isn't done more. It takes up a cycle, so some people probably don't want the delay. 2 out of 3 women will be receptive with 120 hours of progesterone and in the UK they seem to take a trial and error approach to IVF. The ERA seems to be marketed towards women who have had unsuccessful transfers.

There is evidence for the microflora, I read a book on preparing the endometrium for IVF success and I was convinced to do it after reading the chapter on the subject, it cites this study, https://doi.org/10.1016/j.ajog.2016.09.075 which separated women with more than 90% lactobacillus vs those with less than 90% lactobacillus, the outcomes were statistically significant:
Implantation 60.7% vs 23.1%
Pregnancy 70.6% vs 33.3%
Ongoing pregnancy 58.8% vs 13.3%
Live birth 58.8% vs 6.7%

So hopefully this explains why at 0.00% I have never had a BFP.

Unfortunately getting a sample from the uterus is fairly invasive, it isn't as easy as taking a swab. In some studies they have swabbed the transfer catheter tip, but the best way to assess the microflora is to get a biopsy. It isn't painful, they just use suction to remove the stuff that's removed with menstruation.

The EMMA and ALICE can be done alone, my friend is having a stand-alone EMMA after the trio test showed issues with her microflora which she's had treatment for. They put her on the mock FET again.

If I were you I'd be inclined to do a mock FET, you will take estradiol, they will monitor your lining, you'll then be on progesterone for 120 hours, they'll bring you in and take the sample and send it off to the lab. The ERA is relevant for a 2 year period. So this way if you move on to IVF at some point in the next 2 years you'll know about your transfer window. While also knowing about the microflora.

@kennetrose and no I wouldn't say it picks up stuff that doesn't need treating. I would say this about a lot of the other tests I have though!

If you have one of the bacteria that cause chronic endometritis, then that needs treating or you can develop Ashermans syndrome (adhesions and scarring).

If there is less that 90% lactobacillus then you'll need antibiotics and probiotics to resolve this, it isn't exactly invasive treatment and those study outcomes in my last post speak for themselves.

Thanks @Gardenlady543 that's exactly the kind of thing I needed to hear!

And while we're not at IVF stage yet, if we do get there then as you say having done the ERA won't hurt, even if it's the EMMA and ALICE I'm most concerned about at this stage.

I imagine the set up of test itself is similar to a HyCoSy? Oddly my clinic offer the endometrial trio both under anaesthesia and without, which is strange. If it's so bad you need to be knocked out why give the choice. But if it's not that bad, why not just tough it out like you have to for a HyCoSy because general anaesthesia is a hassle. The price difference is £500 so I know which I'll opt for.

Hope I hear back from my doctor today. We're having to take this cycle off for various reasons so keen to do the test this cycle and make the break worth something! Then I can get back to paying hundreds of pounds per cycle knowing we've done all we can to maximise our chances.

@kennetrose that sounds like I plan. I didn't find the biopsy painful, it is uncomfortable, because there's a speculum, in which is never comfortable. In my case it took three attempts, this is very unusual. They ask you to come with a comfortably full bladder, put in the speculum, one person will put an ultrasound scanner on the abdomen and the other will use the image for guidance and use suction to remove a sample from the stuff that comes out with menstruation. I would say take a couple of paracetamol about an hour before and you should be fine.