PUPO

Did all the houseworkey tasks before we left. Guy at DHs work got taxi for us. Arrived at Intersono and saw very serious looking couple from Ireland, but they left as we arrived, so no real chance for chat. I thought how frivolous we were compared to them and it occurred to me that they might have had bad news and we might yet. As indeed we did.

Usual routine and there I am in stirrups. Told the good news that we have 3 blasts to put in and 3 to freeze. Then ultrasound lady chats to dr lubov. Dr Lubov takes a good look and says "have you been taking progynova?" "no", I reply. "not the little blue pills?" "no, I have been taking divigel.". She looks unhappy and says that my lining is too thin, but they will transfer the eggs as they are ready. She seems quite depressed and says we can try progynova but it may be too late for 5 day blasts. I try not to be worried.

They then leave me for the 10 mins, but forget about me (or maybe they expected me to go to recovery by myself?) So I happily lay there thinking good thoughts and assuming that it was better to stay there really than move too soon. After over 20 mins, a nurse says curtly, Please Move. So I get down and walk to recovery. Lie down and read my book. Text DH that all ok, but lining thin. After another 30 mins am told I can go to loo; again, left to find my own way. For girls who are going, you go left out of recovery and walk along corridor, past seated area on right and just after are two toilets marked Toilette (I think) on the right. The first one is usually locked and you need to walk past that to the next on the right. Clear?

So back to room, much relieved, and lie down again. Still thinking positives as I read book. Eventually after further 20 mins am told I can go downstairs. Have by now signed consent for freezing (and DH paid the £250) and given pics of our embies. Find DH in waiting area and explain about thin lining, he is clearly mortified.

Eventually, Lyucyna fetches us to get the progynova and I gobble down one immediately. I ask Dr Lubov how thin was my lining and she again looks quite sorry for me and says 7. She asks me if I can get scans in uk and I explain my dr is useless but I could go private at £300+ a pop. DH queries why this would be an issue with so much paid out already, but I explain it won't just be the one ultrasound. And I know it's being careful with my savings, but after they're gone that's it. No more tries. Full stop.

Back to apartment and go mental, searching for any evidence that women can conceive with a 7mm lining. Found 2 thoughts.

First, embryos can implant and mature in the Fallopian tubes ie no effing lining whatsoever. Second, this from an enlightening blog by a Fertility Doctor in New York University....it's a long read, but very enlightening and Dr Licciardi is well qualified, so it gives me hope.


The Endometrium Part III
Last time we went over some of the conventional methods used to increase the lining thickness. What about the less conventional?

Well there’s Viagra. I had a patient try it and she had a baby. I have had many others try without success. The linings measured no thicker on Viagra than off. As with many things there was some initial interest when it was first described, but we never were able to conclude that Viagra does anything. I do not suggest it to my patients.

What about baby aspirin? The studies are also limited, but the results are not compelling enough to convince us that baby aspirin is worth anything. I have heard that some doctors have all of their patients take it regardless of history. Why I don’t know. It seems benign enough, and is probably used by many women who keep it a secret.

What about using blood flow as an indicator? Why look for bad news? If someone could tell you it’s almost impossible to get pregnant with a certain blood flow, fine, but they can’t, so why torture yourself. We don’t know enough about this.

Is there a minimal acceptable thickness and is thicker better? My colleagues and I did a study looking at donor egg recipients and compared pregnancy rates in women with thin and thick linings. The pregnancy rates were the same in women with linings less than 6 mm compared to women with linings 7 mm or greater. Dr. Noyes also did a study looking at recipients and found that there were plenty of pregnancies in women with thin linings, but the rates were a little higher when the lining was greater than 9 mm. Other authors have shown there is no correlation between thickness and pregnancy rates, and others have shown that the pregnancy rates are higher with a thicker lining.

I do not think the pattern matters. The odds of pregnancy don’t seem to be different if the pattern is ring (or triple) or homogenous. I have found that if the uterus is sharply retroverted, the pattern is commonly homogenous, probably just having to go with angle of the ultrasound waves.

If I had to summarize the general feelings of most infertility doctors, I would say that we are a happier when the lining is thicker, and we may try things to thicken things up a bit, but in the end we take what we can get. Many patients have told me they heard that the target lining is over 9 mm. This I can say is not the case at all.

So let’s say for example I have an IVF patient whose maximum lining is 6 mm. I am not overly worried about this, but will review things and see if there is anything that can be done. I may mention to her that the lining looks a little thin, but would also say it’s not a cause of great concern. Any thicker does not even get a mention. Thinner will get more of a discussion. If her cycle does not work I will try to get it thicker next time, probably using estrogen patches early in the cycle. In many cases the lining remains the same.

For IVF, some doctors freeze all of the embryos and try to get the lining thicker in a high dose estrogen frozen cycle. I have never done this because I do not think it helps. I think you may hurt some embryos with the freeze, and I doubt the lining will get much thicker or much better in the frozen cycle.

This all sounds OK until we have a patient who is not getting pregnant, and also has a thin lining. Question: is it really the lining? Maybe yes and maybe no. I currently have a woman who has tried IVF 5 times with average embryos and a 9 mm lining. Why isn’t she getting pregnant? The point is some women have a thin lining, but a different reason for not getting pregnant.

Some women bail out and go to a gestational carrier, and are successful. In their case it seems the problem was the lining. But few women want to or can afford to go with a carrier.

In summary, the thickness of the lining is not as important as many doctors and patients make it out to be. However, there are some women with thin linings who cannot get pregnant, and for some of them, the lining is the reason for their infertility. Because the treatment of infertility is a game of odds, trying, even when it looks like there are factors against you, is the best thing to do. After that, it’s time for third opinions and opening up to the less conventional options.

That’s it for

Dr. Licciardi

ABOUT ME

DR. LICCIARDI
I have been practicing infertility at NYU for 17 years. Basic infertility, reproductive surgery, ovulation induction, IVF, and egg donation are all areas of my expertise. Most of my patients are from New York , but people come to see me from other states and other countries. You can read all about me at my website, DrLicciardi.com.


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