Thin Endometrium & Infertility(Part – I) , Dr. Sharda Jain , Life Care Centre

Thin Endometrium
& Infertility
(Part – I)
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar

• Healthy seed in not enough to get a
healthy sapling unless it grown on
fertile soil.
• Similarly healthy embryo needs
receptive endometrium for successful
implantation.
Hard Facts

USP OF ENDOMETRIUM
Human endometrium is highly regenerative
tissue. It’s regenerative potential is
comparable to
The Bone Marrow
The epidermis
The intestine
It goes through 400 menstrual cycle of regeneration,
differentation , & shedding during a woman's
reproductive cycle.

USP OF ENDOMETRIUM
Each month 4-10 mm of endometrium grows
within 4 to 10 days in the proliferative phase,
under the influence of increasing circulating
oestrogen levels.

The process of Regeneration completes during
menstruation itself as the surface of the
endometrium is rapidly covered & the
process is completed within 48 hours after
the start of menstruation .
USP OF ENDOMETRIUM

Hard Facts• Histologicaliy , endometrium consists of
Superficial functional layer (upper 2/3rd ).
• During proliferative phase all components of
endometrium (glands, stroma and endothelial
cells) demonstrate proliferation
• It is maximum on 8 to 10th day of cycle, which
corresponds to peak oestrogen level along with
maximum oestrogen receptors.

Preparation of endometrium is directed
towards the
cycle phase of receptively which is known as the
'window of implantation' (WOI).
Window of Implantation
The WOI is described as the period of mid-luteal phase
from day 19 to the day 24, when implantation can take
place.
There is increased mitotic activity, increased nuclear
DNA and cytoplasmic RNA synthesis to prepare for
blastocyst implantation.

Endometrial receptivity during
the window of implantation
depends on the Following:
1.Endometrial thickness
2.Endometrial pattern
3.Endometrial and sub
endometrial blood flow

Endometrium can be evaluated by,
• Transvaginal sonography (TVS),
• Sonosalpingography,
• Hysterosalpingopraphy (HSG),
• Hysteroscopy, and
• Histopathological examination of
endometrial biopsy.
Endometrial Evaluation

ENDOMETRIAL EVALUATION
• Evaluation of endometrial pattern
thickness and blood flow is done by
ultrasonography with colour
Doppler.
• Patients with thin endometrium also
merit a hysteroscopy, if it was not
done before.

• Hysteroscopy may reveal intrauterine
adhesion, endometrial polyp, fibrosis, frank
or silent endometritis.
• However, Newer technique like chromo
hysteroscopy helps to detect silent
endometritis in otherwise normal looking
endometrium found in regular hysteroscopy.
Hysteroscopy

Intrauterine adhesion is found in
8- 10% women with recurrent
implantation failure.
Evidence suggest that
hysteroscopic removal of
adhesions improves fertility
outcome.
Intrauterine Adhesions

A recent systemic review found that
hysteroscopic removal of endometrial
polyp resulted in doubling of the clinical
pregnancy rate in women undergoing
intrauterine insemination.
Bosteels,J. Weyerrs : Hum. Reprod. Update 16, 1-11., 2010
Our Team Feels
“Hysteroscopy should
become part of infertility work- up”

ENDOMETRIAL THICKNESS
& PREGNANCY RATE
A number of researchers have proved that
thickness of pre-implantation endometrium
is directly related to positive pregnancy
outcome .
Pregnancy rate was found to be highest
among the group who had trilaminar
endometrium with 10 – 12.9mm thickness
and no pregnancy when thickness is less
than 7 mm

Endometrial Thickness &
Pregnancy Rate
• Dickey and colleagues (1993) found no
pregnancy if endometrial thickness was
<7mm.
• Pregnancy rate was higher (12% vs 8%)
in the trilaminar vs non trilaminar group
and even higher at 39% when
endometrium is both, more than 6mm
and trilaminar.

One of the most challenging
problems faced in treatment of
infertility is to deal with poor
endometrium during ovulation
induction or preparing endometrium
before embryo transfer.
Management of Thin
endometrium is big a challaenge!!

Important causes of poor endometrium
growth during ovulation induction are:
1. Endometrial resistance to oestrogen.
2. Reduced blood flow.
3. Over -exposure to testosterone.
4. Permanent damage to the basal
endometrium
Causes of Thin Endometrium

• Clomiphene citrate (CC) is most
commonly used and most effective drug
for ovulation. But because of its anti
oestrogenic effect on endometrium,
pregnancy rate is much less than
ovulation rate (40% vs 80%) and 25 % of
those who conceive may end in
abortions
ANTI OESTROGENIC EFFECT OF
CLOMIPHENE CITRATE

Clomiphene citrate
Clomiphene most consistently affects the
thickness of endometrium. Histologically
there is reduction of glandular density and
increase in the number of vaculolated cells.
On moleculer level, while serum oestradiol
level increases in women on clomiphene, but
the oestrogen receptors in endometrium
decrease as the endometrium become
thinner.

Clomiphene citrate
• Research shows that oestrogen and
progesterone receptor ratio is related to
endometrial echo pattern.
• Ratio of progesterone oestrogen
receptor concentration is less in non
trilaminar endometrium.

Reduced of Blood flow
• Akihisa Takasaki at al reported that
thin endometrium is due to high
blood flow impedance of uterine
radial arteries.uterine blood flow is
an important factor for
endometrial growth.
Takasaki A et al
Fertil , steril 2010 , 93(6) 1851-8

According to this study, high blood flow
impedence of uterine radial artery (RA)
impairs growth of glandular epithelium
and result in decrease in vascular
endothelial growth factor (VEGF) which
in turn causes poor flow to
endometrium
Takasaki A et al
Fertil , steril 2010 , 93(6) 1851-8

Decreased blood flow is associated with
decreased endometrial growth .
It is measured by resistance index (RI) /
pulsality index (PI) in radial artery of
uterus in late follicular phase.
Takasaki A et al
Fertil , steril 2010 , 93(6) 1851-8

FAMOUS STUDY
Color flow Doppler of endometrium and
uterine arteries have been extensively
studied by Steer et al and they have found
that NO PREGNANCY OCCURRED IF THE PI OF
UTERINE WAS >3 AND THERE WAS NO SPIRAL
ARTERY Blood flow in the endometrial zones.
Steer CV et all : Human Reproduction. 1990;5:391 -5

OESTRGEN & R I / P I
Estrogen produces a vasodilatory
effect on the uterine arteries.
It has been seen that RI, PI of uterine
artery drops with increasing
estradiol levels.

Androgen & Thin
Endometrium
Excessive ovarian androgen can also
compromise oestrogen induced
endometrial growth.
Luteinizing hormone (LH), primarily acts
on ovarian stroma to produce androgen.
In fact only a small amount of
testosterone is required for optimum
oestrogen production

PCOD
In condition like poly cystic
ovarian syndrome (PCOS), high
LH level leads to Elevated
Androgen Level which may be
the cause for poor endometrial
development besides poor egg
embryo quality

Caution with LH use.
LH containing preparation for
ovulation induction should be
used with caution in this group
of patients. Older woman tend
to have more circulating
bioactive LH than younger
woman

Latent TB
• Persistent thin endometrium
should always be evaluated
for latent tuberculosis as
incidence of genital
tuberculosis is very high in
india (10 to 50 %).

Severe Endometritis
• Permanent damage to basal endometrium
may occur due to severe endometritis or due
to vigorous curettage following abortion etc.
severly damaged basal layer usually leads to
synechiae or amenorrhoea. For all practical
purpose, completely damaged basal
endometrium cannot be regenerated.

Conclusion
• Evaluation and detection of any endometrial
abnormality is one the cornerstone in the
management of infertility
• Endometrial receptivity during the
implantation window depends Endometrial
thickness , Endometrial pattern,
Endometrial and sub endometrail blood
flow

This is one of most challenging problems faced in
tratment of infertility is to deal with poor
endometrium during ovulation induction or
preparing endometrium before embryo
transfer.
• Optimum endometrium i.e. 7 mm
preovulatory is must for achieving pregnancy –
• But treatment modalities for achievement of
this, are still evolving
Conclusion

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Thin Endometrium & Infertility (Part – I) , Dr. Sharda Jain , Life Care Centre

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