Assignment Task:
Task:
BACKGROUND
Endometrial scratching (with the use of a pipelle biopsy) is a technique proposed to facilitate embryo implantation and increase the probability of pregnancy in women undergoing in vitro fertilization (IVF).
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We conducted a pragmatic, multicenter, open-label, randomized, controlled trial. Eligible women were undergoing IVF (fresh-embryo or frozen-embryo transfer), with no recent exposure to disruptive intrauterine instrumentation (e.g., hysteros- copy). Participants were randomly assigned in a 1:1 ratio to either endometrial scratching (by pipelle biopsy between day 3 of the cycle preceding the embryo- transfer cycle and day 3 of the embryo-transfer cycle) or no intervention. The primary outcome was live birth.
RESULTS
A total of 1364 women underwent randomization. The frequency of live birth was 180 of 690 women (26.1%) in the endometrial-scratch group and 176 of 674 women (26.1%) in the control group (adjusted odds ratio, 1.00; 95% confidence interval, 0.78 to 1.27). There were no significant between-group differences in the rates of ongoing pregnancy, clinical pregnancy, multiple pregnancy, ectopic preg- nancy, or miscarriage. The median score for pain from endometrial scratching (on a scale of 0 to 10, with higher scores indicating worse pain) was 3.5 (interquartile range, 1.9 to 6.0).
CONCLUSIONS
Endometrial scratching did not result in a higher rate of live birth than no inter- vention among women undergoing IVF. (Funded by the University of Auckland and others; PIP Australian New Zealand Clinical Trials Registry number, ACTRN12614000626662.)
The success rate of in vitro fertil- ization (IVF) remains modest; the proba- bility of live birth is approximately 25 to 30% per initiated cycle.1-3 Endometrial scratching, which involves the obtaining of an endometrial- biopsy sample with a sampler such as the pipelle, has been proposed to increase the success rate of IVF. It has been postulated that the endome-trial injury, or “scratch,” that results from the biopsy may facilitate embryo implantation by inflammatory and immunologic mechanisms.4-7 Pooled results from randomized trials have suggested benefit from this procedure, especially in women in whom implantation had failed previ- ously.8
However, many trials have had methodo- logic limitations, including small size, and un- clear methods of randomization and concealment of trial-group assignments; some have been published only as conference abstracts.9-12 One of the larger trials with a robust design showed a lack of benefit from endometrial scratching; a subgroup analysis suggested lower rates of preg- nancy with this intervention than with no inter- vention among women in whom implantation had failed repeatedly.10,13 Despite conflicting evi- dence, a recent survey showed that 83% of fertil-ity clinicians in the United Kingdom, Australia, and New Zealand offer or recommend endome- trial scratching, which can cost patients as much as £400 (approximately $500 U.S.).14
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