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As an IVF specialist, I often see infertile patients with complex and unusual problems. One of the most challenging problems to deal with is that of the patient with a poor endometrium or a thin uterine lining. Embryos need to implant in the endometrium, and an optimal endometrium is thick and trilaminar.
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.
The affecting factors
However, sometimes this does not happen. We do know that the growth of the endometrium depends upon:
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 color, 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.
We need to systematically examine all these 3 possibilities, so that we can pinpoint what the problem is in the individual patient, and then try to correct it. If the doctor finds the endometrium is poor during the IVF cycle, often the best option is not to transfer the embryos but to freeze all of them.
The patient can then be treated with high doses of exogenous estrogens, to see if this causes the endometrium to become thick. If the endometrium grows well, it's then possible to transfer the frozen embryos after thawing them into an estrogen primed endometrium.
Others have tried using vaginal viagra to try to improve endometrial blood flow. Since there is no reliable method to assess uterine blood flow, the next step is to determine whether the endometrium has been damaged or not. There are two possible causes of end-organ damage when the endometrium is nonresponsive.
The egg freezing option
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.
Other treatment options
A recent interesting paper ( Successful treatment of unresponsive thin endometrium, Fertility Sterility, 2011) has described the use of intrauterine perfusion of Granulocyte 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 interventions, surrogacy is the final treatment option which has a very high success rate.