Transcription
Experts in artificial insemination like myself learn what factors can lead to artificial insemination failure. A successful in vitro fertilization cycle requires a normal, healthy embryo and a normal, healthy uterus. Chronic endometritis, which is the presence of inflammation in the endometrium, is one factor that causes artificial insemination failure. Stay tuned and I will explain. Patients with chronic endometritis have no symptoms. They have no differences in their periods, nor do they have pain or discharge. How then is endometritis diagnosed? The uterine cavity is lined with cells that are collectively referred to as the endometrium. Abnormalities in the uterine cavity such as scar tissue, polyps, and fibroids can lead to artificial insemination failure. These abnormalities can be detected by looking inside the uterus with a hysteroscope or by performing an X-ray test known as an HSG or by performing a saline ultrasound. However, endometritis is difficult to detect. It cannot be detected using HSG or saline ultrasound. Using hysteroscopy, some patients with chronic endometritis may be found to have redness or a small growth known as micro-granulomas. However, the most accurate way to diagnose chronic endometritis is to take a sample of the endometrium, known as an endometrial biopsy, and look at it under the microscope. Even under the microscope, it can be difficult to determine if a patient has endometritis. The hallmark of endometritis is finding a type of white blood cell known as a plasma cell. It can be difficult to pick out plasma cells under the microscope. Can you see the plasma cells in this sample? I cannot. The best way is to look at the endometrium using a special type of microscopic staining procedure known as CD138 staining. This highlights the plasma cells and makes it easier for anyone to see them. Many women who have a normal uterus may have a few plasma cells. Patients who we say have chronic endometritis have a higher number of plasma cells visible under the microscope like this. What causes endometritis? Like the vagina, the uterine cavity on the inside contains bacteria. We can divide bacteria into two types: good and bad. Good bacteria do not cause any problems with a woman's reproductive capacity. Bad bacteria are what cause the patient's body to produce plasma cells. Remember, plasma cells are white blood cells. White blood cells are what the body uses to fight off bad bacteria. How does endometritis cause artificial insemination failure? It is not really known how chronic endometritis causes artificial insemination failure. It may be the bacteria themselves. It may also be chemicals produced by the plasma cells to get rid of the bad bacteria. Or a combination of the two. At this point, we do not really know. How is chronic endometritis treated? Antibiotics are currently used in an attempt to get rid of chronic endometritis. The first antibiotic used to treat endometritis is called doxycycline. Doxycycline treats a variety of bacteria, is easy to obtain, and is inexpensive. The treatment course is usually twice a day for two weeks. Studies show that chronic endometritis can be eradicated using doxycycline about 75% of the time. The way doctors determine if treatment is successful is by repeating a second endometrial biopsy. If there are only a few plasma cells left or none, then the patient can proceed with embryo transfer. If the number of plasma cells is still high, then the patient will receive a second course of treatment with some different antibiotics. About 75% of patients who are not cured after the first course of doxycycline will be cured after the second course. This means that a few patients, about 10%, will have persistent chronic endometritis. These patients may have antibiotic-resistant bacteria or some other cause such as viruses or even an immune system problem. We do not really know. Is treatment of chronic endometritis effective in reducing artificial insemination failure? Yes. There are a number of studies that have shown that this type of treatment can reduce IVF failure rates. For example, this study was published in 2021. Researchers performed endometrial biopsies after couples had two or three failed embryo transfers. They divided the patients into three groups. The first group was patients who did not have chronic endometritis. The second group was patients who had a few plasma cells without taking antibiotics. The third group was patients who had a few plasma cells after receiving antibiotic treatment. There was no difference in these three groups in the percentage of patients who became pregnant or delivered. They then compared patients who had chronic endometritis who were cured with antibiotics and those who were not cured, in other words, those who had persistent chronic endometritis. They found that those patients who had persistent chronic endometritis had lower pregnancy rates and lower live birth rates. Chronic endometritis is one cause of IVF failure. Patients undergoing artificial insemination should have an endometrial biopsy to look for chronic endometritis and treat it if found. Patients with persistent endometritis should be advised that they may have a lower chance of pregnancy but it is still reasonable to attempt embryo transfer.