P-532 Understanding the utility of hysteroscopic endometrial peeling in women with implantation failure
Authors: Luna M , Alkon T , Cassis D , Hernandez-Nieto C 
Published: June 2023

Abstract

Study question
Does hysteroscopic endometrial peeling improve reproductive outcomes in women with implantation failure (IF) undergoing a single euploid embryo transfer (SEET)?

Summary answer
Women with IF may benefit from intraoperative endometrial peeling prior to a SEET.

What is known already
Preimplantation genetic testing for embryonic aneuploidy (PGT-A) has been suggested as a strategy to improve implantation rates in women with IF. However, after controlling for the genetic status of the embryo, implantation rates still vary from 40-70%, suggesting that other factors aside from the ploidy of the embryo contribute with the cause of IF. We previously demonstrated that hysteroscopic endometrial peeling enhances implantation in women with IF. However, our study was limited by only including frozen embryo transfers of unscreened embryos. We aim to analyze the clinical utility of hysteroscopic endometrial peeling in women who underwent a SEET.

Study design, size, duration
A retrospective, cohort study included infertile patients with IF diagnosis who underwent endometrial peeling through hysteroscopy and subsequently a SEET from January 2016 to December 2022. Only the first transfer after the hysteroscopic endometrial peeling was included in the analysis.

Participants/materials, setting, methods
Women &lt;41 years, with IF, normal saline sonogram, and no previous uterine surgeries were segregated into two groups: A) 66 patients underwent hysteroscopic endometrial peeling, which consists of removing the superficial endometrial layer of the whole uterine cavity with hysteroscopic biopsy forceps, and B) 38 controls who did not undergo surgical endometrial peeling. All patients underwent a subsequent SEET.

Main results and the role of chance
In total 104 women were included in the cohort. No differences were found in age, body mass index, baseline FSH, AMH, baseline antral follicle count, previous number of stimulation/IVF cycles, number of embryos transferred, and, embryonic quality among cohorts. Evaluating the endometrium, no differences were observed in the endometrial pattern, however, the endometrial thickness was thicker in group B (8.4±1.5mm vs 9.2±1.3mm, p = 0.02). When analyzing the subsequent SEET cycle, women in group A had higher implantation (51.8% vs 40.6%, p = 0.001) and clinical pregnancy rates (63.5% vs 31.4%, p = 0.009). No difference was found in clinical loss rates (9.4% vs 10.1%, p = 0.06) among cohorts. Of the patients who underwent surgical endometrial peeling, 18.1% (12/66) had the following incidental intraoperative findings: mild intrauterine and/or cervical adhesions (5/66, 0.07%), endometrial polyps (10/66, 15.1%), polypoid endometrium (8/66, 12.1%). 64.3% of the patients with incidental findings became pregnant.

Limitations, reasons for caution
This study is limited by its retrospective nature. Additionally, in patients with noted uterine pathology, appropriate surgical management was administered in the same setting, this could have biased the results. Future randomized controlled trials are needed.

Wider implications of the findings
This study continues to support the possible benefit of mechanically peeling the superficial endometrial layer through hysteroscopy to increase implantation rates in women with IF who undergo a SEET.

Trial registration number
NA