Endometrial biopsy in subfertile women undergoing intrauterine insemination (IUI) cycles improves pregnancy rates Tumanyan A, Tchzmachyan R, Grigoryan H, Hambartsoumian E. Fertility Center Yerevan, Armenia www.FertilityCenter.am

Background Fertility Rate Implantation is a major challenge in human reproduction. Fertility Rate A healthy young woman 20-22% IVF - 25%-35% 3/4 embryos are not implanting successfully. A healthy young woman has approximately a 20% chance to achieve a successful pregnancy with each menstrual cycle. Even when embryos are to be of high quality implantation rates remain around 25%-35% Thus, implantation failure is a common experience since the majority of embryos do not to implant successfully. The European IVF-monitoring program 2005 www.FertilityCenter.am

Background Uterine factors: Major causes of implantation failure thin endometrium, poor endometrial receptivity in the recent years among the various potential causes of implantation failure, uterine factors such as thin endometrium, poor endometrial receptivity, have received the most attention www.FertilityCenter.am

Background Endometrial receptivity can be modulated by Modulation of endometrial receptivity Endometrial receptivity can be modulated by A. biological factors Cytokines Growth factors Mechanical factors Endometrial scratching (biopsy) It has been shown that endometrial receptivity could be modulated by a multitude of biological and even mechanical factors, such as endometrial scratching. www.FertilityCenter.am

Background Biopsy stimulates the uterus’ receptivity Endometrial local injury Inflammation white blood cells growth factors cytokines Thus, recently it has been shown that local injury of the endometrium produces an inflammatory reaction resulting in increased white blood cells (leukocytes such as macrophages) which secrete growth factors and cytokines. These substances regulate blastocyst implantation and placental development. This stimulates the uterus’ receptivity to the embryo and increases the success rate of live birth. blastocyst implantation placental development www.FertilityCenter.am

Background Biopsy of the endometrium in IVF patients: Clinical studies in IVF patients Biopsy of the endometrium in IVF patients: Doubles the rates of implantation Doubles the rates of pregnancy In clinical trials it was demonstrated that local injury of the endometrium during a spontaneous menstrual cycle doubled the rates of implantation and pregnancy in IVF patients www.FertilityCenter.am

Background Endometrial biopsy – IUI - ? Clinical studies in IUI patients Endometrial biopsy – IUI - ? However, studies on the use of endometrial injury in intrauterine insemination (IUI) cycles are not available. www.FertilityCenter.am

Objective To investigate the effect of endometrial biopsy on the clinical outcomes of IUI This study attempted to investigate whether the use of endometrial injury affects the clinical outcomes of IUI www.FertilityCenter.am

MATERIAL AND METHODS Patients Subfertile women with infertility of unknown reason Study period: 2008 - 2012 For this purposes we recruited subfertile women with infertility of unknown reason who apply to our Fertility Center from time period of 2008 -2012. www.FertilityCenter.am

MATERIAL AND METHODS Study design 94 patients randomisation Group A (47) Group B (47) endometrial biopsy mock  biopsy Following is the study design 94 patients were randomly divided into two groups. Subjects of Group A underwent endometrial biopsy in the cycle preceding the IUI, while group B subjects underwent mock endometrial biopsy at the same day of previous cycle. COH and IUI we started on the next cycle, Overall up to 4 cycles were performed if patients were not pregnant 4 cycles of COH and IUI 4 cycles of COH and IUI www.FertilityCenter.am

MATERIAL AND METHODS Protocol hCG 5000 IU IUI Biopsy/ mock Menopour Didrogesteron CC 50 mg Our protocol included a one time procedure of local injury of the endometrium or mock biopsy on day 20 of the menstrual cycle that precedes a COH + IUI treatment. Both endometrial sampling and mock biopsy were performed using a "Pipelle" biopsy catheter. Starting from day 3 of next cycle all patients received the same treatment: stimulation of ovulation by CC and gonadotropins and IUI, according to our standard protocols. If the pregnancy did not occur patients continue receiving COH and IUI without additional endometrial biopsies.   -20 D1 d3 d 7 d 9 d 13 d14…………days of cycle www.FertilityCenter.am

MATERIAL AND METHODS Inclusion criteria Women Infertility of unknown reason Infertility > 2 years N hormonal and anatomical status history of regular menstrual cycles < 38 y old Male N spermogramm. an accent was made on rigorous definition of the inclusion criteria: In women 1) age less than 38 years, 2) Infertility during 2 years or more in the absence of hormonal and anatomical disorders 3) history of regular menstrual cycles in male: normal sperm quantity and quality www.FertilityCenter.am

Main outcomes Pregnancy rate (per cycle) after COH and IUI Cumulative pregnancy rate after 4 attempts of COH and IUI Pregnancy complications www.FertilityCenter.am

Secondary outcomes Endometrial thickness Histological pattern of endometrial tissue www.FertilityCenter.am

Group t-test, Student’s t-test Statistics Group t-test, Student’s t-test P < 0.05 www.FertilityCenter.am

RESULTS Age (years) 28.2 ± 1.01 27.7 ± 0.9 NS Demographics and Clinical data Group A Group B P-value   Age (years) 28.2 ± 1.01 27.7 ± 0.9 NS Infertility (years) 5.4 ± 0.9 5.2 ± 0.7 NS BMI (kg/m2) 22.8 ± 1.77 23.1 ± 1.9 NS Motile sperm count (mln) 64. 4 ± 12,4 69.7 ± 19,2 NS Age of subjects, duration of infertility, body mass index, basal hormone levels and sperm parameters were comparable between the two groups www.FertilityCenter.am

RESULTS Secondary outcomes Endometrial thickness (mm) 9,6 ± 0,6 9,9 ± 1,6 NS Complication from biopsy: - infection, - high T, - bleeding, - severe cramping None none N/A Also Endometrial thickness was not different between the two groups in all cycles. There were no any complication related to the procedure of endometrial samplings or mock sampling www.FertilityCenter.am

Histological findings (Group A) Secondary outcomes Histological findings (Group A) Histological pattern % -Small Polyp(s) 36.4 -Glandular Hyperplasia 29.7 -Chronic Endometritis -Luteal phase defect 44.6 Histological data shown on this table Suggests that at least in part the cause of the infertility may be attributed to endometrial factors, invisible during transvaginal ultrasonography www.FertilityCenter.am

Effect of endometrial biopsy in subfertile   RESULTS Main outcome Effect of endometrial biopsy in subfertile women undergoing COH and IUI Group A Group B P value Cumulative pregnancy rate Cumulative live birth rate 27/47 (55.3%) 20/47 (42.5%) 18/47 (38.3%) 11/47 (23.4%) < 0.05 According to Main outcome of this study there is a significant difference in in terms of pregnancy rate between two groups. This, the cumulative clinical pregnancy rate was 55.3% in group A while it was only 38.3% in group B (p<0.05) Accordingly the live birth rate was 42.5% in group A while it was 23.4% in group B (p=0.024) As one can see “take home baby’s” rate in a group of patients with endometrial biopsy is almost twice as much as in a group B. Fertility Center Yerevan Armenia

Pregnancy rate (%) per cycle after endometrial biopsy RESULTS Main outcome Pregnancy rate (%) per cycle after endometrial biopsy P<0.05 It is worthy to note, that the difference in clinical pregnancy between two groups was observed only on the first IUI but not on the 2nd 3rd and 4th cycles. Thus, clinical pregnancy rate in 1st IUI cycle after biopsy in group A was 29.7% while in group B only 14.8%. www.FertilityCenter.am

The prevalence of pregnancy rate in relation to the IUI cycles RESULTS Main outcome The prevalence of pregnancy rate in relation to the IUI cycles 1st IUI 51.8% 2nd IUI 20.8% 3rd 14.8% 4th Indeed when one look at the data within the group of pregnant women more than 50 % of all pregnancies occurred on the first after the endometrial biopsy cycle. www.FertilityCenter.am

Complications of pregnancy RESULTS Main outcome Complications of pregnancy Group A Group B P value Abortions: - Early Abortions - Late abortions 7/27 (25.9%) 6/27 (22,2%) 1/27 (3.4%) 6/18 (33.3%) 0/18 <0.05 N/A Interestingly the abortion rate was also significantly less in a group A compared to group B. www.FertilityCenter.am

CONCLUSIONs   Endometrial biopsy prior to an IUI cycle significantly improves the rates of clinical pregnancy and live birth in women with infertility of unknown reason Thus, results of our study suggest that local injury to the endometrium prior to an IUI cycle improves the rates of clinical pregnancy and live birth in women with infertility of unknown reason. www.FertilityCenter.am

THANK YOU! www.FertilityCenter.am Improving implantation continues to pose a major challenge to clinicians working in the field of human reproduction. www.FertilityCenter.am