Do not hesitate to order following three tests after 3 -4 cycles
of futile treatment (particularly ovulation induction by clomiphene) to exclude
poor endometrium
as the sole cause of persistent infertility Inspite
of ovulation induction by Clomiphene/ Letrozole/ Tamoxifen (all are oral agents
to promote ovulation-and to achieve pregnancy). Such three highly recommended tests
are 1) saline hystero-salipngography 2) All reproductive hormones prolactin in particular and 3)
Endometrial Blood Flow Pattern by Color Doppler
(an improved variety of USG):-- If such tests are further delayed more
frustration will ensue among doctor and couple. Therefore one should have no hesitations
in ordering such useful tests...
What should be normal appearance of inner wall of womb on
fertile period i.e. at cycle day 11-16 day of menstrual cycle?
This should look like triple line pattern in sonography (imaging the uterus) &
measure about 9-12 mm in thickness. But pregnancy has been documented at
a lower thickness as low as 6 mm but in such situation the chance of pregnancy is
uncommon.
Even if pregnancy occurs in such a case there are
higher rate of miscarriage due to poor functional
development of inaner lining of womb...
Aim
of Fertility specialist:-So our aim is to achieve ET of at least 10 mm at fertile
time (cycle day 11-16 day) thereby to achieve a successful
pregnancy outcome.
Poor Endometrial Function:-. in some women endometrium grows
in thickness as per norms in sonography but appears homogeneous and not as triple line
even on day 21- i.e. on the
presumed day of nidation( the
supposed day of implantation of fertilized egg to get attached to inner wall of
womb). These are called functional inadequacy
(unresponsive endometrium).
The following are the discussions about causes & what
can be done in such situations-where repeatedly sonography warns us that endometrial
thickness is lagging behind?
Let highlight about the causes of endometrium not attaining typical thickness
of 9-12 mm at day 2-16 of menstrual cycle? What are the causes and how
best to rationally investigate such cases - where repeatedly endometrium fails
to grow in the middle part of menstrual cycle?
Causes
are:-
1) Endometrial adhesions, 2) benign small polyp inside the
uterus 3) chronic anovulation- no
cyclical release of eggs-as happens in polycystic Ovarian disease so improper hormone
milieu-more male hormones in endometrium and poor development of friendly growth factors and enzymes
promoting functional growth of endometrium , 4) low amh –which is an
reflection of dysfunction of ovarian follicles.5) Raised
prolactin hormone. There are other causes that will be picked as we
proceed.
By Usg , especially by 3-D USG may easily reveal polyp but saline hystero-salipngography
will also help to delineate any polyp and sometimes some other abnormalities of
inner wall of womb like Intra-uterine
adhesions(common causes of adhesions and therefore loss of function of
womb are past abortions/ infections/ Tuberculosis etc
etc). If by SIS (saline sono -grapy-a
very commonly employed investigations in Fertility clinics to asses inner wall
of womb and see tubal patency), endometrial distortions / irregularity in Sonography
(imaging the womb) speaks in favour of adhesions inside the womb.
.
Triple line endometrium is
very important for receptivity but not mandatory for nidation or
onward proper growth of embryo. Nutrition o to foetus may not be interfered
with.
In such situation where SIS or ordinary 2D or better 3 D USG
reveals irregularity
inside womb: - :-One should always opt for
hysteroscopy without delay to avoid dissatisfaction amongst the concerned woman
and to formulate rational Treatment plan i.e. decision of such adhesions inside
womb.
Endometrial Blood Flow Pattern by Color Doppler
(an improved variety of USG):--is an important tool of
investigation of receptivity of womb. If blood supply to inner walls of uterus is optimum i.e. without any resistance in the
vessels àthen
hopefully function of inner wall of womb is good and in such cases one can disregard thickness of inner wall of
womb particularly if blood flow to the innermost layer this endometrium is good .
In such situation possibility of poor endometrium is hard to believe.
Unfortunately blood supply pattern is seldom assessed unless in IVF cycle.
...
Some women do not produce triple line endo. One can
try HORMONE REPLACEMNT TERAPY for 1-2 cycles along with sexual abstinence.
There are several protocol to use preceded by hysteroscopy.
D Add Oestrogen to improve ET: One can supplement
by adding oestrogens i.e. Progynova bad or tds for promoting growth of lining
of womb and augment implantation of fertilized ovum at uterus.
Metformin (an insulin sensitizer):- may be of use if
endometrium is not triple line but homogeneous. This may be male hormone excess
as evidenced in Poly cystic ovarian disorders. Metformin will indirectly reduce
male hormone in blood and endometrium too.
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