Association between proliferative-to-secretory endometrial compaction and pregnancy outcomes after embryo transfer: a systematic review and meta-analysis
Authors: Feng Shenghui , Wang Bangqi , Chen Shen , Xie Qiqi , Yu Lamei , Xiong Chaoyi , Wang Shuang , Huang Zhihui , Xing Gengbao , Li Ke , Lu Chuming , Zhao Yan , Li Zengming , Wu Qiongfang , Huang Jialyu 
Published: February 2024

Abstract

STUDY QUESTION
Does the change in endometrial thickness (EMT) from the end of the follicular/estrogen phase to the day of embryo transfer (ET) determine subsequent pregnancy outcomes?

SUMMARY ANSWER
Endometrial compaction from the late-proliferative to secretory phase is not associated with live birth rate (LBR) and other pregnancy outcomes.

WHAT IS KNOWN ALREADY
Endometrial compaction has been suggested to be indicative of endometrial responsiveness to progesterone, and its association with ET outcome has been investigated but is controversial.

STUDY DESIGN, SIZE, DURATION
A systematic review with meta-analysis was carried out. PubMed, EMBASE, and Web of Science were searched to identify relevant studies from inception to 18 November 2022. The reference lists of included studies were also manually screened for any additional publications.

PARTICIPANTS/MATERIALS, SETTING, METHODS
Cohort studies comparing ET pregnancy outcomes between patients with and without endometrial compaction were included. A review of the studies for inclusion, data extraction, and quality assessment was performed by two independent reviewers. The effect size was synthesized as odds ratio (OR) with 95% CI using a random-effects model. Heterogeneity and publication bias were assessed by the I2 statistic and Egger’s test, respectively. The primary outcome was LBR. Secondary outcomes included biochemical pregnancy rate (BPR), clinical pregnancy rate (CPR), miscarriage rate (MR), ongoing pregnancy rate (OPR), and ectopic pregnancy rate (EPR).

MAIN RESULTS AND THE ROLE OF CHANCE
Seventeen cohort studies involving 18 973 ET cycles fulfilled the eligibility criteria. The pooled results revealed that there were no significant differences between endometrial compaction and non-compaction groups in LBR (crude OR (cOR) = 0.95, 95% CI 0.87–1.04; I2 = 0%; adjusted OR (aOR) = 1.02, 95% CI 0.87–1.19, I2 = 79%), BPR (cOR = 0.93, 95% CI 0.81–1.06; I2 = 0%; aOR = 0.88, 95% CI 0.75–1.03, I2 = 0%), CPR (cOR = 0.98, 95% CI 0.81–1.18; I2 = 70%; aOR = 0.86, 95% CI 0.72–1.02, I2 = 13%), MR (cOR = 1.09, 95% CI 0.90–1.32; I2 = 0%; aOR = 0.91, 95% CI 0.64–1.31; I2 = 0%), and EPR (cOR = 0.70, 95% CI 0.31–1.61; I2 = 61%). The OPR was marginally higher in crude analysis (cOR = 1.48, 95% CI 1.01–2.16; I2 = 81%) among women with compacted endometrium, but was not evident in adjusted results (aOR = 1.36, 95% CI 0.86–2.14; I2 = 84%). Consistently, the pooled estimate of LBR remained comparable in further subgroup and sensitivity analyses according to the degree of compaction (0%, 5%, 10%, 15%, or 20%), type of ET (fresh, frozen, or euploid only), and endometrial preparation protocol (natural or artificial). No publication bias was observed based on Egger’s test.

LIMITATIONS, REASONS FOR CAUTION
Although the number of included studies is sufficient, data on certain measures, such as EPR, are limited. The inherent bias and residual confounding were also inevitable owing to the observational study design. Furthermore, inconsistent definitions of pregnancy outcomes may affect the accuracy of our pooled analysis.

WIDER IMPLICATIONS OF THE FINDINGS
Given the lack of prognostic value, assessing endometrial compaction or repeated EMT measurement on the day of ET may not be necessary or warranted.

STUDY FUNDING/COMPETING INTEREST(S)
This work was supported by Natural Science Foundation of Jiangxi Province (20224BAB216025), National Natural Science Foundation of China (82260315), and Central Funds Guiding the Local Science and Technology Development (20221ZDG020071). The authors have no conflicts of interest to declare.

REGISTRATION NUMBER
CRD42022384539 (PROSPERO).