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How is endometrium prepared for implantation?

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5 fertility expert(s) answered this question

Answer from: Patricio Calamera, MD, MSc, ObGyn

Gynaecologist, Specialist in Reproductive Medicine
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The estrogen in the first part of the embryo development which makes the endometrium getting thicker and we the correct characteristic with the triple line and then, the most important one, which is the progesterone which is the one that get ready though that those cells and that endometrium er to be receptive for the embryo. So basically the most important is the progesterone but it’s also a sort of a complete hormonal regulation that it’s involved in the receptivity of the endometrium.

Answer from: Rami Wakim, MD FRCOG FACOG FICS

Gynaecologist, Consultant in Reproductive Medicine
Phoenix Hospital Group
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With regards to endometrium preparation in the context of a frozen embryo transfer, it is a simpler procedure rather than the procedure that you have to undertake to have e.g. IVF stimulation with a medication. Why? Because it’s simply a matter of adjusting the lining thickness with some simple oral medications. We start with an oral medication which is an estrogen tablet. You can start with taking it twice a day or three times a day – it depends on the clinic or the protocol. And in general terms, we have a scan after like a week or so and another scan to make sure that the lining is thick enough. After the first scan after a week, if the lining is still debatable and not reaching the level that we are happy with, you might be asked to increase the dose, maybe up to 4 times a day, or add vaginal tablets, too. Once we reach the level of 7 millimeters or more, we can plan ahead for the embryo transfer. And we do that by supplementing progesterone or starting to give you some progesterone supplementation in conjunction with the timing of the embryo transfer for the embryologist. So it is a scheduled procedure and I don’t have to stick to a certain time. I have a little bit of malleability so whenever we decide on the day of the embryo transfer, 5 days before we will start the progesterone supplementation.

In the past, we used to give what we called ‘an injection’ on day 21 before starting the preparation, in order to shut the ovaries down and not producing any hormones. And this is to avoid the unlikely phenomenon of spontaneous ovulation during the stimulation. However, most of the clinics now have a trend to avoid this medication because of the very minimum percentage of this happening.

So as we know, we start with tablets on day 2, we get you back after a week and we have a scan. If there are any signs that dominant follicles started or there is ovulation or a corpus luteum, then obviously this cycle is cancelled. And then we restart again by administering a GnRH agonist on day 21. This makes sure that it will not happen – or it can still happen but at the very minimum. And once you have your period, we start with tablets again, as usual.

Answer from: Marcel Štelcl, MUDr, PhD

Gynaecologist, Chief Physician
ReproGenesis
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There are two ways to prepare the body for embryo transfer, or the endometrium for embryo transfer. The first way it’s a natural cycle and the endometrium prepares itself. We do only ultrasound monitoring of thickness of the endometrium, and we measure dominant follicles. We plan ovulation and embryo transfer 5-6 days after ovulation. Then it’s artificial preparation of endometrium by estradiol, which is used orally, vaginally, or by patches or everything together. It’s individual and depends on the thickness of the endometrium, and then we add progesterone, and then we plan the embryo transfer 5-6 days after starting off progesterone.

Answer from: Ali Enver Kurt, MD

Gynaecologist, Specialist in Obstetrics & Gynecology
Vita Altera IVF Center
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There are two ways to prepare the endometrium: to ovulate the patient or to suppress the ovulation with hormonal pills, and to prepare the endometrium for endometrial thickening. For the ovulation, you can let the patient ovulate spontaneously or you can stimulate the patient a little bit to ovulate. The third method is to suppress ovulation. As you maybe know, oral contraceptive pills are working to suppress ovulation and they prevent the patient from getting pregnant.

We similarly work with the medication. We give a little bit higher doses of estrogen than physiological level and with this, we suppress the ovulation of the patient and in the meantime, with the estrogen, we prepare the endometrium to accept the embryo and this takes 13 days from the beginning. 13 days later we establish the patient’s oocytes pick up or ovulation day, and this is day zero. On day five, that is six days after, the patient’s endometrium will be ready for the transfer of the 5th-day embryo. If you give the 3rd-day embryo, then the 3rd day after we do the transfer. If this is a five-day embryo, then 5th day after the 13 days we do the transfer.

Answer from: Lyubov Mykhaylyshyn, MD, Phd

Gynaecologist, Head of IVF department
Medical centre “Alternativa” for Human Reproduction Clinic “Alterntyva”
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There are different strategies for endometrial preparations. Mostly, there are two types of them when the corpus luteum exists or when it is absent. So, for the first group, I belong to the truly natural protocol, which is based on the existence of the natural corpus luteum. In the cycle, we just measure LH surge in the blood or in the urine. And another one is a modified natural cycle where we need to determine the size of the growing dominant follicle and when it reaches 18-20 millimeters we’ll prescribe HCG (human chorionic gonadotropin). We also can induce ovulation by means of Clomid, letrozole, gonadotropins induce the ovulation and the other type of protocols are where the corpus luteum is absent, so that are artificial or programmed preparations of endometrial where we just administer on the estrogen and progesterone. So for years, it has been shown that it’s enough to have just estrogen and progesterone to make the endometrium receptive. But interestingly, recently, we realized that our corpus luteum in the natural cycle produces much more than just estrogen and progesterone. We know now that it produces a lot of vasoactive substances like relaxin, like vascular endothelial growth factor, like active metabolites of estrogen which are also vasoactive, and all of them play an extremely important role in the initiation of placentation. So, it also has been shown recently that the absence of these vasoactive substances can be like a risk factor for the development of preeclampsia during pregnancy. But anyway, in some groups of patients we exclude the presence of corpus luteum; first of all, that are patients with endometriosis because in this group of patients, we need to have some influence on the activity of estrogen receptor, because normally estrogen receptors have to be down regulated by progesterone, but in this group of patients it still works, that is why we have no other choice than to exclude their own corpus luteum to prescribe GnRH agonists and to prescribe only estrogen and progesterone. So now, medicine all over the world is looking at what else we can do; like adding those vascular endothelial growth factors which are produced in the natural cycle by the corpus luteum.

About this question:

What is the process of preparing endometrium for an embryo transfer/implantation?

Can embryo transfer be done straight away after the embryos are ready? The important aspect of any IVF treatment is preparing the patient’s endometrium and making sure it is of correct structure and thickness. How is it done?

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