Fun in the Sun...Dominion style

Sometimes it is hard to get away from the office. Several summers ago we were vacationing on the Outer Banks of North Carolina. The weather was outstanding..hot, sunny and no hurricanes. Meanwhile back in the office I had a patient undergoing a mock cycle in preparation for a frozen embryo transfer (FET). We had frozen all of the embryos from her fresh IVF because of the risk of hyperstimulation and just like the patient that posted to me today on my INCIID bulletin board, this patient also had hypothalamic amenorrhea (more about that in a later question) with a suboptimal endometrial lining.

As we tried to move forward with a FET we hit a roadblock as her uterine (endometrial) lining just would not cooperate. We had tried a bunch of different drugs to ready her lining but I could not get the thickness that I wanted (although I think that the pattern was OK). Our plan that summer was to try another recipe and then do an endometrial biopsy to check the lining. At least that was my plan...

While I was in Corolla one of my most trusted nurses, Mary Ann, called me on my cell. I just happened to be back at the house for lunch. Mary Ann was very apologetic. The patient was getting close to the point in the cycle to start progesterone and set up her endometrial biopsy, but suddenly her lining looked very good and she was hoping to just go for embryo transfer rather than the biopsy.

The only spot in the house where I could get a reliable cell was on the roof deck and it was about 110° in the sun. Mary Ann asked me to call the patient and for the next 30 minutes we went over all the options. While I was roasting at the picnic table on the deck we decided to go ahead with the ET when I returned to DC the following week.

The story has a happy ending...the transfer went well with both embryos implanting and she delivered healthy twins. I can still remember sitting in that boiling sun, talking on the cell phone and wondering if it was the correct decision.

So here is the "Question of the Day" from that beach book "100 Questions and Answers about Infertility" regarding endometrial lining issues:



71. My endometrium is only 6 to 7 millimeters thick. Can I do anything to improve its thickness?


The thickness of the endometrium normally changes throughout the menstrual cycle. During menstruation. the endometrium is shed. Under the influence of the hormone estradiol, the endometrium then regenerates and usually develops to a normal thickness of 8 or more millimeters (mm). When a woman is undergoing infertility treatment, the thickness of her endometrium is regularly measured using ultrasonography. When the endometrium fails to develop to at least 8 mm, the embryo may fail to implant because of endometrial immaturity or dyssynchrony. Although this problem is not very common, when it occurs, it can be difficult to correct. Typical treatments consist of providing additional estrogen early in the menstrual cycle or altering the timing of progesterone administration. Other therapeutic agents include small doses of aspirin (80 to 100 mg per day), and some physicians have prescribed Viagra vaginal suppositories for their female patients with variable success. Some women cannot achieve pregnancy in a fresh IVF embryo transfer cycle but readily become pregnant when the embryos are transferred in a frozen–thawed nonstimulated treatment cycle. On rare occasions, a couple may need to use a gestational carrier to successfully overcome abnormalities involving the endometrium and implantation. Of course, failure of the endometrium to achieve a minimum thickness of 8 mm does not necessarily translate into a problem with the endometrium. In our practice, we have seen many patients with maximal endometrial development of only 4 to 7 mm successfully achieve pregnancy, including delivery of twins. A variety of testing methods to assess endometrial maturity have been proposed, including endometrial biopsy testing for surface proteins called integrins, but such testing is currently considered experimental.