How to Increase Endometrial Thickness for IVF?

UPDATED ON 03RD APR. 2024

Friends as a practicing fertility specialist one of the commonest question and dilemma which we see in our practice is difficulties related to implantation and endometrial thickness. 

It is important to understand that endometrial thickness between 6 to 9 mm is considered to be normal for Indian women. 

Thickness less than 6 millimetre is often classified as something called as a thin endometrium. Thickness more than 12 mm is offer a predictor of poor implantation.

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Aisa couple who is undergoing IVF one of the first and foremost things you should think of is all the other factors, like the embryo quality of the Blastocyst (day 5 embryo), the chromosomal status of the embryo (euploid on evaluation) are established as normal or not. 

It is the euploid embryo that carries an interaction with the endometrium. And this crosstalk between the two of them is a massive dilemma in science currently. 

Patience war undergoing IVF or often extremely anxious and her worried about the result, as a result of which all of them usually follow, the details available to them like the endometrial thickness, pretty closely. This anxiety shoots up even further when I see them having an endometrial thickness that is classified as sub-optimal or something that is below 6mm.

Now as a patient the first question they ask me with, “Sir if the endometrium is not of adequate thickness, will it lead to a failure of IVF after Embryo Transfer“.

So we always explain to them that the data just says that the success rate goes down with thickness below 6mm, but there is no data with says that the success rate becomes zero. 

However, as doctors all of us endeavor to ensure that we try to increase endometrial thickness so that you are patients can often get the best possible outcomes.

The standard protocol used is the HRT Protocol for Endometrial Preparation for embryo transfer. (Shared in an image).

This typically uses oral estrogens to enhance the endometrial thickness. Then after a certain thickness is achieved, typically between 7-9mm, a further study is done using Endometrial Doppler to assess the vascular pattern of the endometrium and if that’s satisfactory, then the patient is scheduled for an Embryo Transfer. 

Before this, at our Shree IVF Clinic in Mumbai, we follow an additional assessment using estrogen and progesterone blood values to schedule and select the patient. Typically Estrogen levels more than 300 and progesterone values less than 1.2 are the patients we select for an Embryo transfer. 

Now, certain additional things are tried for patients who have a poor endometrial thickness. 

Prior to giving treatment, we like to do a detailed assessment, 3D Ultrasound of the endometrial cavity, and if needed then a Hysteroscopic assisted biopsy to rule out Chronic Endometritis. Chronic Endometritis is a known entity in India to cause a persistent thin endometrium, it’s diagnosed using a simple biopsy and associated testing of MUM-1. (A marker specific for plasma cells)

After these assessments turn out to be negative. The patient is typically switched to a Natural Cycle Embryo Transfer or a Modified Natural Cycle transfer protocol. We have shared the protocol below. At our unit, we prefer to give the modified natural cycle protocol based on case selection with letrozole.

The outcomes when a healthy follicle and a healthy corpus luteum are formed are good for the endometrium as it allows a natural peak of estrogen to act on it. The success rates for embryo transfer in these cases are equivalent to the HRT Protocol, and about 50-80% of patients who have a thin endometrium experience the beneficial effects of this protocol.

In some select situations, one needs to do additional procedures like Autologous Stem Cell Therapy of the Endometrium. This is a therapy where progenitor cells which are precursor cells, are extracted using a special technique from the bone marrow and then they are processed using an ultra-low density medium to flush out the other cells a heavy concentration of Progenitor cells is obtained and the procedure is performed.

This therapy is currently considered to be “experimental” and there is a benefit of about 60% which the patient can experience. This procedure is done with the help of hysteroscopic surgery and it is very important to understand that a good hysteroscopic surgery in this case is of vital important to get a success rate.

Endometrial PRP is now considered to be a procedure that does not help to increase the thickness of the endometrium. As a result of this, we use this procedure extremely sparingly. If needed Autologous stem cell therapy is much much better as compared to PRP.  

We do not prefer to give any form of oral supplements in the form of sildenafil citrate, Low Molecular Weight Heparin, or other products that hardly have any benefit. 

Also, an important thing to understand is that there is no specific diet which helps a patient increase endometrial thickness, and hence no such diet changes are recommended. 

Exercises especially in the form of pelvic exercises by Yoga and associated postures which enhance the flow of the blood to the pelvis also don’t benefit in enhancing the thickness of the Endometrium. And all of them are associated with good health, they have no benefit which is proven in enhancing the thickness of the endometrium. 

In India, it is also common to have endometrial TB, as a silent infection that would have occurred in the past, and as a result of this, many women experience idiopathic thin endometrium. A detailed evaluation of hysteroscopy should be done for these patients, which picks up specific signs of old infections, these are the patients who will benefit greatly from Autologous stem cell therapy in the basal endometrium. 

Many of these patients who are going through the stress of having a thin endometrium, must undergo a detailed examination and consultation with a team dedicated to handling these cases.

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