President’s Medal for best medical graduate of year1970-75
Award from DMA on Dr. B.C Roy’s birthday: outstanding contribution to
Vikas Ratan Award by Nations economic development & growth society 2002
Every single menstrual cycle aims at endometrial growth & receptivity which is a steroid-dependent phenomenon & is targeted to create a ‘window of implantation’ which spans from day 20 to 24 of a 28-day cycle.
Barash was the first to introduce the concept of endometrial scratch where he observed that local injury to the endometrium doubles the incidence of successful pregnancies in patients undergoing IVF. Fertil. Steril. 2003, 79, 1317–1322
The trauma can be achieved simply by a pipelle, biopsy curette, or hysteroscope at low cost and with no need of analgesia or anaesthesia
Hysteroscopy is used to treat endometrial pathologies that can interfere with embryo implantation. Benefits of hysteroscopy are beyond the possible ‘injury’ effect only:
Therefore, studies based on hysteroscopy should not be combined with those exclusively based on endometrial biopsy to analyse the scratching effect
Carlos and Bellver Hum Rep.2014, Pundir et al., 2014
Cicinelli E, Matteo M, Tinelli R, Lepera A, Alfonso R, Indraccolo U, et al. Prevalence of chronic endometritis in repeated unexplained implantation failure and the IVF success rate after antibiotic therapy. Hum Reprod 2015; 30:323–30. (49–51).
ES has been used in IVF cycles with variability:
Fresh embryo transfer cycles (Barash et al., 2003; Baum et al., 2012; Gibreel et al., 2015; Guven et al., 2014; Inal et al., 2012; Karimzadeh et al., 2009; Mahran et al., 2016; Narvekar et al., 2010; Nastri et al., 2013; Raziel et al., 2007; Shohayeb and El-Khayat, 2012; Singh et al., 2015; Yeung et al., 2014) FET in HRT cycles (Aflatoonian et al., 2016; Dunne and Taylor, 2014) natural FET cycles (Jennifer Sze Man Mak et al.,2017)
In total, 901 participants included in 2 randomized (n = 193) and six non-randomized controlled studies (n = 708). The quality of studies was variable. Meta-analysis showed that clinical pregnancy rate was significantly improved after LEI in both randomized & non-randomized studies.
Pooling of 7 controlled studies (four randomized and three non-randomized), with 2062 participants, showed that local endometrial injury induced in the cycle preceding ovarian stimulation is 70% more likely to result in a clinical pregnancy as opposed to no intervention
Authors’ conclusions Endometrial injury performed prior to the embryo transfer cycle improves clinical pregnancy and live birth rates in women undergoing ART.
This opinion paper, analysed the methodological and plausibility problem beneath ‘the Scratching Case’.
It has been suggested not to dilute evidence-based medicine by a vicious circle created by the over-exploitation of inadequate or insufficient data to compute incorrect or incomplete conclusions through systematic reviews and meta-analysis.
To summarize > 300 publications can be found on this topic, but only four RCTs with poor quality were analysed in 3 meta-analyses published in the same year with the same conclusion.
ES was first suggested a decade ago by Barash as a simple intervention to improve endometrial receptivity in patients undergoing ART. A decade later, this intervention is being widely advertised by some of our colleagues on their web pages, and patients are paying to undergo the ‘scratching cycle’ before their ART treatment cycle.
This intervention must not be advertised as an established practice to improve implantation until real good data demonstrates that it does. We, doctors, have to remind ourselves of the Hippocratic Oath of Primum non nocere which means first, do not harm.
Though more studies are still needed one should consider this evidence is probably better than that existing for all other interventions aiming to improve the reproductive outcomes of women with RIF with fortunately several new studies on the horizon.
Why are the authors compelled to convince readers against endometrial scratching?
Is endometrial scratching expensive and/or risky?
Endometrial biopsy using a Pipelle is an affordable procedure, and millions have been performed per year for diagnostic indications for decades as a safe and well-tolerated procedure.
Although current evidence suggests some benefit of ES, we need evidence from well-designed trials that avoid instrumentation of the uterus in the preceding three months, do not cause endometrial damage, stratify the results for women with and without recurrent implantation failure (RIF) and report live birth.
ES performed sometime during the month before the start of OS improves chances that a woman will achieve live birth and clinical pregnancy.
Moderate-quality evidence suggests that if 26% of women achieve live birth without endometrial injury, between 28% and 48% will achieve live birth with this intervention.
Contrary to this, endometrial injury performed on the day the eggs are picked up reduces the chances of pregnancy.
The ESI may improve IVF success in patients with two or more previous ET failures undergoing fresh ET. The ESI timing and technique seem to play a crucial role in determining its effect on embryo implantation.
Result(s):10 studies included (1,468 participants).
Intervention group higher LBR (RR 1.38, 95% CI 1.05–1.80) and clinical PR (RR 1.34, 95% CI 1.07–1.67)
No difference in multiple PR, miscarriage rate, and EPR.
Double luteal ESI with flexible pipelle had greatest effect on LBR (RR 1.54, 95% CI 1.10–2.16) and clinical PR (RR 1.30, 95% CI 1.03–1.65).
ESI was beneficial for patients with two or more previous ET failure, but not for women with single previous failed ET.
No effect seen in women with frozen-thawed ET cycles
This Cochrane review included 9 RCT’s (1512 women) who underwent endometrial scratching and were trying to get pregnant from intercourse or IUI with unexplained subfertility.
Overall the results suggest a benefit from ES. However, all the studies have significant limitations and so the results may be biased. Thus not possible to say with any confidence whether ES can increase the probability of pregnancy in this group of women.
ESI is expected to be safe, although clear evidence about its short-term and long-term complications is warranted.
ESI lead to higher CPR (OR 2.27) & OPR (OR 2.04) vs controls. Not higher risk of multiple pregnancy (OR 1.09), MR (OR 0.80), or EPR (OR 0.82).
Subgroup analysis based on ESI timing showed higher clinical pregnancy rate (OR 2.57) and ongoing pregnancy rate (OR 2.27) in patients receiving ES in same cycle of before hCG but not in patients in previous cycle.
Poor evidence quality (GRADE of evidence: low) that ESI improves CPR (OR 2.27, P<00001) and OPR (OR 2.04, P=.004) in patients undergoing IUI without increasing the risk of multiple pregnancy, miscarriage, or ectopic pregnancy (GRADE score: low/very low).
Results support clinicians by providing an updated summary on ESI use in IUI and advising about the uncertainties in the real chances of ESI improving CPR and OPR.
Despite the novel evidence provided by our analysis, there is still a need for further robust, high-quality RCTs to confirm the effectiveness and safety ESI before routinely recommending its use in patients undergoing IUI cycles.
Methods/design: The PIP trials are 3 multi-centre, RCTs designed to test 3 separate hypotheses:
Whether endometrial injury increases the probability of live birth in women or couples
Anticipated effect of endometrial scratching considered separately in two sub groups (80% power, α=0.05)
Recurrent implantation failure (≥1 prior unsuccessful embryo transfers)
Non-recurrent implantation failure (no prior unsuccessful embryo transfers)
Overall target: 1300
Primary analyses performed on the whole trial population