Fertility specialists’ views, behavior, and attitudes towards the use of endometrial scratching in Italy
Authors: Palomba Stefano , Carone Domenico , Vitagliano Amerigo , Costanzi Flavia , Fracassi Alice , Russo Tiziana , Del Negro Serena , Biello Altiero , Di Filippo Aldo , Mangiacasale Antonio , Monaco Antonio , Ranieri Antonio , Ermini Beatrice , Barba Bruno Francesco , Castello Claudio , Di Guardo Federica , Pastorella Francesco , Bernasconi Elena , Tricarico Ezio Michele , Filippi Francesca , Polsinelli Francesco , Monte Giuseppe Lo , Sosa Fernandez Loredana M. , Galletta Marco , Giardina Paolo , Totaro Pasquale , Laganara Roberto , Liguori Roberto , Buccheri Matteo , Montanino Oliva Mario , Piscopo Rosita , Iuliano Assunta , Innantuoni Nicola , Romanello Irene , Sinatra Francesco , Liprino Annalisa , Thiella Roberto , Tiezzi Alessandra , Bartolotti Tiziana , Tomasi Alessandra , Finocchiaro Valeria , Thiella Mario , Fuggetta Giuseppa , Messineo Sebastiano , Isabella Francesco , Tripodi Marcello , Iaccarino Stefania , La Sala Giovanni Battista , Papaleo Enrico , Caserta Donatella , Marci Roberto , Somigliana Edgardo , Guglielmino Antonino ,   the Italian Society of Human Reproduction (SIRU)
Published: July 2023

Abstract
Background
Endometrial scratching (ES) or injury is intentional damage to the endometrium performed to improve reproductive outcomes for infertile women desiring pregnancy. Moreover, recent systematic reviews with meta-analyses and randomized controlled trials demonstrated that ES is not effective, data on the safety are limited, and it should not be recommended in clinical practice. The aim of the current study was to assess the view and behavior towards ES among fertility specialists throughout infertility centers in Italy, and the relationship between these views and the attitudes towards the use of ES as an add-on in their commercial setting.

Methods
Online survey among infertility centers, affiliated to Italian Society of Human Reproduction (SIRU), was performed using a detailed questionnaire including 45 questions with the possibility to give “closed” multi-choice answers for 41 items and “open” answers for 4 items. Online data from the websites of the infertility centers resulting in affiliation with the specialists were also recorded and analyzed. The quality of information about ES given on infertility centers websites was assessed using a scoring matrix including 10 specific questions (scored from 0 to 2 points), and the possible scores ranged from 0 to 13 points (‘excellent’ if the score was 9 points or more, ‘moderate’ if the score was between 5 and 8, and ‘poor’ if it was 4 points or less).

Results
The response rate was of 60.6% (43 questionnaires / 71 infertility SIRU-affiliated centers). All included questionnaires were completed in their entirety. Most physicians (~ 70%) reported to offer ES to less than 10% of their patients. The procedure is mainly performed in the secretory phase (69.2%) using pipelle (61.5%), and usually in medical ambulatory (56.4%) before IVF cycles to improve implantation (71.8%) without drugs administration (e.g., pain drugs, antibiotics, anti-hemorrhagics, or others) before (76.8%) or after (64.1%) the procedure. Only a little proportion of infertility centers included in the analysis proposes formally the ES as an add-on procedure (9.3%), even if, when proposed, the full description of the indications, efficacy, safety, and costs is never addressed. However, the overall information quality of the websites was generally “poor” ranging from 3 to 8 and having a low total score (4.7 ± 1.6; mean ± standard deviation).

Conclusions
In Italy, ES is a procedure still performed among fertility specialists for improving the implantation rate in IVF patients. Moreover, they have a poor attitude in proposing ES as an add-on in the commercial setting.