IVF scratching: Are women putting themselves through a painful procedure for nothing?

In January 2019, there was an excellent randomised trial published on endometrial scratching prior to IVF.

This procedure goes back many decades when women had a curette and many seemed to be more fertile afterwards.   The idea of a scratch as a more refined procedure was taken up enthusiastically but this latest excellent study suggests that it should not be used so widely. However, we must also remember that the uterus is an essential place for the pregnancy to develop and we must always be thinking about its suitability for embryo implantation.

This requires some kind of examination and the benefit to IVF may be more complex than simply scratching the lining. For example, the passing of a catheter or tube through the cervix to dilate the cervical canal can make embryo transfers easier or can help the Clinician in determining whether there is a problem in the cervix. Many scratch biopsies are done in the context of a hysteroscopy when other important problems such as polyps or adhesions or uterine congenital abnormalities can be discovered and treated.

Furthermore, an embryo scratch biopsy can also be used for tissue diagnosis for critical factors such as hyperplasia, endometritis and immune studies.

Clearly, the routine undertaking of the scratching went too far and it would be wrong to think scratches should be done prior to every cycle as this data shows.   Equally though, especially in those with repeated IVF failure, further exploration of the uterus is essential. It should be done on a limited number of occasions and the Clinician should try to obtain as much information as possible from such an invasive procedure.

In summary, a scratch should be reserved for those that repeat IVF failure and then as part of a wider assessment.

Original article by medical reporter Sophie Scott

IVF scratching: Are women putting themselves through a painful procedure for nothing?

Key points:

  • A global study found endometrial scratching is not effective in boosting fertility in IVF
  • Patients are charged up to $700 for the add-on treatment
  • The IVF peak body says doctors should stop recommending it to couples

Michelle Ross would have done anything to have a second child.

After enduring years of heartbreak and disappointment, the 33-year-old finally turned to IVF for help.

“I lost eight babies in 12 years. We had tried for so long. We were happy to do anything we could to get pregnant,” she said.

She said doctors told her it was unlikely she would have another baby because she had severe endometriosis.

When she was told a painful procedure called endometrial scratching might boost her chances of conceiving, she did not hesitate.

“They told me the scratching made the uterus more sticky during IVF,” she said.

A doctor inserted a catheter into Ms Ross’s uterus and used it to superficially wound the lining.

The theory is that the scarring causes inflammation, which makes it easier for embryos to implant in the uterus.

Ms Ross described endometrial scratching as eight out of 10 on the pain scale.

“I was in pain for a week,” she said.

She got pregnant a month after the procedure, and went on to have a healthy baby girl she named Jessica.

But a new global study has cast doubt on whether the procedure played any role in Ms Ross’s successful pregnancy.

Experts find no evidence that endometrial scratching works

A group of fertility researchers from around the world compared the number of live births from women who underwent endometrial scratching to those who didn’t.

A human egg being fertilised through IVF

Of the 1,364 women studied, 180 women had babies in the group that had endometrial scratching, while there were 176 births in the control group.

Researchers concluded that the procedure, which is widely offered by clinics across Australia, did nothing to boost a woman’s chances of getting pregnant through IVF, describing it as “painful and pointless”.

Study lead Professor Cindy Farquhar from the University of Auckland said it was clear the procedure did not boost a woman’s chance of giving birth.

“On the basis of this study — which is the biggest and most robust to date — we would encourage IVF clinics to stop offering it,” she said.

The research has been published in the prestigious medical journal, the New England Journal of Medicine.

More than 80 per cent of Australian fertility clinics offer endometrial scratching, usually to couples who have failed to get pregnant after several rounds of IVF.

The procedure can cost up to $700.

“This study provides the opportunity to tell patients that the evidence doesn’t stack up,” said Louise Johnson, head of the Victorian Assisted Reproductive Treatment Authority (VARTA).

VARTA offers support and information to couples struggling with fertility.

Ms Johnson believes many would-be parents are desperate for success, and may put themselves through dubious procedures in a bid to get pregnant.

“Couples going through IVF are extremely vulnerable, and clinics have an obligation to inform patients about treatments that can cause pain and won’t increase the chance of conception,” she said.

Obstetrician Professor Ben Mol from Monash University said doctors had been offering couples the scratching procedure for many years, despite a real lack of strong scientific evidence that it worked.

“It is great news that we now know that this technique does not help,” he said.

“Luckily, we didn’t find it caused any harm, apart from bleeding and pain.”

He said other add-on IVF treatments such as steroids and treatments to reduce immune cells in the uterus should also undergo better evaluation.

“The concern is that there are more of these add-on therapies offered without a sound scientific base, and many will turn out not to be effective once properly evaluated,” he said.

IVF peak body says it should no longer recommend the scratch

Professor Luk Rombauts from the Fertility Society of Australia, which represents medical staff working in fertility clinics, said the study findings will change what advice is given to IVF patients.

“I would no longer recommend [endometrial scratching] for patients who come through the door for IVF,” he said.

However Professor Rombauts said some patients who had already had the scratching before becoming pregnant through IVF may still want it.

Michelle cuddles her baby, Jessica.

“I would like to think doctors would tell patients about the risks and benefits and the best available evidence,” he said.

“Patients often read a lot online about possible IVF treatments and we will need to educate our patients about this new evidence.”

Ms Ross said she would never know for sure what impact the scratching procedure had on her body, but believed it helped her conceive.

“I really don’t know if it helped, but I would ask for it again if I ever had IVF again,” she said.

Miscarriage on the rise but there’s still not enough help for grieving mothers

Written by JANE HANSEN, The Sunday Telegraph

GABBI Armstrong will never forget going for her baby’s 10-week ultrasound and being told “I’m sorry, there is no heartbeat”.

The Botany mum has two children now but endured six miscarriages over a two-year period. On average, one in five confirmed pregnancies are thought to end in miscarriage.

Mrs Armstrong felt there were no resources to help grieving women, so she teamed up with another mum, Samantha Payne, who had also had two miscarriages, to form the Pink Elephants Support Network.

The online network aims to help women negotiate the complex emotions that come from an empty womb and a broken heart.

“You still feel pregnant, but there is no baby, there are a lot of tears and you have to know it is OK to feel devastated, it’s OK to be jealous of other pregnant women and it’s OK to feel angry and lose confidence,” she said.

The Royal Hospital for Women now offers a miscarriage care kit designed and supplied by Pink Elephants in their early pregnancy unit and they have also started information seminars for midwives and emergency department staff on how to emotionally support women through miscarriage.

“We want to help professionals to better support women going through this,” Mrs Armstrong said.

Mrs Armstrong had already travelled an emotional rollercoaster with eight rounds of IVF, 19 embryos transferred — and each ending with no pregnancy.

At age 35, Mrs Armstrong did fall pregnant naturally with son Hugh. When he was just seven months old, she fell pregnant again — and the nightmare of miscarriage began.

“There was no heartbeat, I was floored, beyond devastated,” the now 45-year-old said.

“Miscarriage really gets swept under the carpet, it’s so early, people say it’s not really a baby, it’s common, but it’s all your hopes and dreams.”

According to fertility expert Dr Gavin Sacks from IVF Australia, miscarriage rates are on the rise as women delay childbirth.

“From your mid-30s onwards, miscarriage rates become more frequent from about one in six in your early 30s to one in four at 40 and one in two at 45,” Dr Sacks said.

He said many women feel they suffer without acknowledgment.

“There’s a lot to be gained by recognising miscarriage,” he said.

Dr Sacks said there was hope for women who suffered multiple miscarriages.

“Women need to remember it is common and secondly, that it is often nature taking its course as a result of genetic abnormality but, thirdly, the chances of having a successful pregnancy the next time round are quite high, even if you have had three miscarriages, research shows you have a much higher change of success next time around,” he said.

Original article here.

Miscarriage research: the bioengineers taking a fresh look at pregnancy

Written by 

For an engineer, Dr Michelle Oyen has spent a lot of time with placentas recently. “It’s a really weird organ, half baby, half mother. It must begin functioning at the same time as it develops. There’s nothing else like it in the body,” she says.

Oyen is committed to discovering why pregnancies go wrong. And fascinated by applying engineering principles to medical research in her post as reader in bioengineering at the University of Cambridge. “You can’t experiment on pregnant women – it’s totally unethical and impossible.” Instead, her team take high-resolution images of donated placentas to understand the geometry of blood vessels. They then use these to build 3D online models to understand how blood flows around the placenta. “We are trying to understand how cells involved in building a placenta know how to invade the right amount into a uterus,” she says. “They have to get it just right, and it’s a poorly understood process.”

Currently, one in five pregnancies are believed to end in miscarriage, and 85% of these happen in the first 12 weeks of pregnancy. Parents often have no idea why – and it can be heartbreaking for the 200,000 people (women plus partners) affected every year.

“I believe some of the problems in healthcare are some of the biggest problems in modern society,” says Oyen. “As engineers we have different tools to biologists and doctors. The more people you have approaching a problem from a different perspective, the more likely you are to understand it.”

Around the country, research collaborations are forming between universities. “There seems to be an explosion of bioengineers interested in pregnancy,” says Oyen. “But compared with other conditions it’s been understudied – from a bioengineering perspective at least.” In 2013 to 2014, miscarriage research charity Tommy’s says that the most up-to-date figures it was able to obtain indicate that just 4% of the government’s health research budget was spent on reproductive health and childbirth, with only a fraction of this going towards miscarriage research.

At the largest miscarriage research centre in Europe, hosted by the University of Birmingham, scientists and medics from Birmingham, the University of Warwick and Imperial College London are collaborating to research the causes of miscarriage, stillbirth and premature birth. Tommy’s National Centre for Miscarriage, funded by the charity, investigates potential genetic causes, including a possible link to damaged DNA in sperm, and other research avenues, such as the role of bacteria. Using clinical data from around the country, scientists hope to develop computer modelling that can predict the risk of miscarriage. “We are working to establish the role of the immune system as a prognostic factor in women with recurrent miscarriage, and incorporating these factors to predict pregnancy outcomes more accurately,” says Prof Arri Coomarasamy, director of the centre.

Currently the centre is developing clinical trial apprenticeships, based at Birmingham, for researchers and clinicians to build up relevant skills. To work in the field, you don’t necessarily need a bioengineering qualification – Coomarasamy doesn’t, although she does have three other degrees. “All kinds of engineering backgrounds – mechanical, chemical, materials – are perfectly well-suited to the work we do,” she says. “The thing about engineering is the tools we bring to the table – such as computational modelling – can be applied to any problem.”

Original article here.

IVF: Financial incentives may be driving decisions and advice of some fertility doctors

By Wendy Lipworth, Brette Blakely and Ian Kerridge

About one in 25 Australian babies are conceived using assisted reproductive technologies (ART), including in-vitro fertilisation (IVF).

These interventions are almost all offered in private fertility clinics, backed by a thriving fertility industry.

Women who are deemed eligible for IVF can have an unlimited number of cycles subsidised by Medicare, but out-of-pocket costs can range from several hundred to several thousand dollars per cycle.

Our research, published today in the journal Human Fertility, suggests the money being made from IVF could be subtly changing the advice doctors give.

Informed consent

Although IVF is a well-established procedure, it is not without its risks.

These include ovarian hyperstimulation syndrome, where hormone levels rise too much (causing abdominal swelling, nausea, vomiting and diarrhoea); obstetric complications such as premature delivery; and psychological distress, especially if the process fails.

Although long-term outcomes for children conceived using IVF appear to be similar to non-IVF children, questions remain about possible harmful impacts, including developmental abnormalities and cancer.

Given the financial, physical and psychological burdens of IVF, patients must be able to make informed decisions about whether to pursue these treatments in the first place, and when to stop.

So it’s concerning that couples are often oversold the likelihood of success.

This “overselling” may be a result of the way information about “success rates” is conveyed.

A 30 year-old woman has a 40 per cent chance of a live birth after a single complete IVF cycle (so, after all viable embryos have been transferred). A 40 year-old woman, in contrast, may have a 10 per cent chance of a live birth following a complete IVF cycle.

The same 30 year-old might have a 70 per cent chance after six complete cycles, while the 40-year-old might only have a 25 per cent chance.

Success rates of IVF may appear deceptively higher if success is defined as clinical pregnancy (of just six to eight weeks), or live birth at a stage that is generally incompatible with sustained life (as early as 20 weeks or 400 grams).

Alternatively, rates may appear lower if they are reported per embryo transfer rather than per complete cycle.

Commercialising IVF

In 2014, two major players in the ART industry were floated on the stock exchange for more than $300 million each.

This reportedly boosted some fertility specialists’ annual salaries to more than $1 million. But what about the effect of commercialisation on patients and taxpayers?

To investigate this question, we conducted in-depth interviews with a range of professionals involved with ART in Australia, including obstetricians, policy advisers, researchers and counsellors.

Interviewees said financial motives were influencing ART practices in Australia, with some women offered IVF who don’t actually need it. Others are offered repeated cycles of treatment, even when they aren’t likely to succeed.

This dynamic was seen to be facilitated by the current Medicare system. The safety net protects patients by limiting the amount they have to pay out of pocket once they reach a certain threshold.

But it can also potentially encourage over-servicing and over-charging. There is no cap on the number of procedures that can be offered or the fees that can be charged.

Doctors can therefore offer additional services for higher fees without patients incurring significant additional costs. This has serious implications for the health system.

As one of the people interviewed in the study observed:

“I just think the business model and the fact that it takes advantage of Medicare, and the fact that the Medicare safety net helps spread the risk of out-of-pockets from the patient to the taxpayer is just basically being used to make some people a lot of money.”

Importantly, nobody who was interviewed suggested ART clinicians were deliberately misleading patients for their own financial benefit. The problem identified was subtler and reflected a deep ambivalence at the heart of medicine.

On the one hand, doctors are expected to be committed to their patients, research participants or the general public, and not concerned primarily with their own enrichment.

On the other hand, doctors need to earn a living and, in Australia at least, do so in a health system that supports — and even depends upon — publicly subsidised private practice.

There is no reason these interests are incompatible but their co-existence raises questions about how commercial interests may influence practice.

The commercialisation of ART raises questions not only about the motives and behaviour of clinicians, but also about how those seeking ART services should be viewed.

They could be seen as patients who are potentially highly vulnerable and to whom clinicians have a duty of care requiring them to play an active role in guiding patients in their healthcare choices even if this means some interventions are strongly discouraged.

Or they could be viewed as consumers free to choose whatever interventions they want in a healthcare marketplace, no matter how much they cost or how unlikely they are to succeed.

This idea is, of course, predicated on the assumption consumers will be provided with accurate information about risks, costs and benefits which, as many others have noted, cannot be assumed.

Although the Human Fertility study was small and does not represent the views of all professionals involved with ART in Australia, it reveals concerns about the impact of commercial interests in ART have not simply been drummed up by the media for dramatic effect.

It is time for an honest discussion about the Australian fertility industry, and about the role of money in medicine more generally.

Originally published in The Conversation

Women could be told if they are at high risk of miscarriage with new tests

Women could be told from the beginning of pregnancy if they are at high risk of miscarriage or premature birth thanks to a highly accurate new tests.

Leading scientists have described as “very exciting” a breakthrough technique which can detect serious complications months in advance, giving doctors the chance to intervene and save lives.

It means that being told the likelihood of a devastating event could soon become a routine part of a doctor confirming a woman is pregnant.

Miscarriage charities welcomed the new technique.

Obstetricians can currently provide expecting mothers little or no warning of premature birth, miscarriage or preeclampsia, a life-threatening blood pressure disorder which kills up to 1,000 babies a year.

But researchers have now identified a handful of molecules unlocking the fundamental biology of these conditions, which are present long before any symptoms arise.

Scientists have so far devoted largely unsuccessful efforts to searching for blood biomarkers from the placenta.

However, the team at the Laboratory of Premature Medicine and Immunology in San Francisco turned their attention to the placental bed, the thick mucous membrane that lines the uterus during pregnancy.

Their discovery of 30 molecules relating to gene expression will enable newly pregnant women to undergo to a simple blood test able to determine their risk.

Britain has one of the highest rates of premature birth in Europe, with roughly one in nine babies born before 37 weeks gestation.

If doctors are aware a woman is at high risk of early delivery they can monitor her more closely and potentially use hormone drugs to delay the date of birth.

While there little that can be done to prevent miscarriage, the test can help women prepare for the eventuality.

By contrast, preeclampsia can be monitored and better managed the earlier it is detected.

Around three per cent of pregnant women suffer the condition where blood pressure is raised to levels that threaten both mother and child.

The only cure is to deliver the baby, meaning doctors can sometimes be forced to induce dangerously premature births.

Tim Child, assistant professor of obstetrics and gynaecology at Oxford University, said the new research was “very promising” and described the statistical relationship between the discovery of blood biomarkers in patients in the study and their subsequent complications as “very, very strong”.

Presented at the American Association of Reproductive Medicine annual congress in Texas, the four combined studies involved 160 births.

Searching for microRNA in blood immune cells, the team were able to predict miscarriage and late preeclampsia with around 90 per cent accuracy and premature birth before 34 weeks with around 89 per cent accuracy.

Premature birth between 34 and 38 weeks was predicted with 92 per cent accuracy.

Professor Simon Fishel, an IVF pioneer and founder of Care Fertility, said a warning highlighting blood flow problems in the placental bed, potential treatments include blood thinning drugs such as heparin.

“Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.

“Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.”

He added that to be ‘forewarned is forearmed’ when dealing with pregnancy complications.

Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.

Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.’

“Our combined analysis supports the idea that the Great Obstetrical Syndromes have a common biological origin early in the first trimester that can be detected throughout the first trimester using peripheral blood cell microRNA,” the researchers said.

Roughly one in four pregnancies end in miscarriage, although this reduces to one in six pregnancies where the mother knows she is pregnant.

Around 80 per cent occur in the first 12 weeks’ gestation.

Barbara Hepworth-Jones, Vice Chair of the Miscarriage Association, said: “This is very welcome news.

“Much research is still needed before we fully understand the causes of pregnancy complications including miscarriage, and can then look for treatments.

“But this holds real hope for the future.”

A recent study found that giving aspirin to women at high risk of pre-eclampsia could reduce their chance of preterm pre-eclampsia by 60 per cent.

View original article here.