CAUSES OF THIN ENDOMETRIUM
- Endometrial resistance to circulating estrogen
- Reduced blood flow to the endometrium
- Over exposure to testosterone
- Permanent damage to the basal endometrium
- Infection like MTB
- Asherman syndrome
PERSISTANT THIN ENDOMETRIUM
- Evaluate for STB-incidence of genital tuberculosis is very high in India.
- For all practical purposes, completely damaged basal endometrium cannot be regenerated
- Permanent damage to basal endometrium may occur due to severe endometritis or due to vigorous curettage following abortion.
- Assessment by USG(TVS)
- Rapid noninvasive means of assessing the endometrium
- Thickest part of the endometrium should be measured
- Endometrium of 6mm or less is associated with 100% negative predicitive value for conception
- ET 8-14mm is best endometrium on day of HCG trigger
- ET >16mm or <7mm is not associated with good prognosis.
MODALITIES TO INCREASE ENDOMETRIUM
- Oral estradiol 2mg TDS
- High dose of Vitamin E
- Oral L-arginine supplementation
- Sildenafil Citrate 25mg TDS
- Low dose Aspirin
- Nitroglycerine patch
- G CSF
- Gylcoprotein, growth factor and cytokine
- Sources- endothelial cells, monocytes, macrophages and fibroblasts
- Reproductive tract- follicular, granulosa cells, endometrial cells, and cells from decidual, placental and various fetal tissues
- Promotes neutrophil proliferation and maturation
- Produced by recombinant DNA technology from Ecoli into which the human G-CSF gene has been inserted.
- G-CSF involved in a wide variety of reproductive functions:
- Maintaining healthy endometrium
- Useful biomarker of oocyte competence before fertilization
Improve implantation rate and successful pregnancy outcome in infertility, IUI and IVF procedures
- Absorption: not absorbed orally. Rapidly absorbed following C injection/infusion into uterine cavity and peak serum concentrations are generally attained within 4-5 hours.
- Distribution: Rapidly distubuted, highest concentration in bone marrow, adrenal glands, kidney and liver.
- Half-life: is approx 3.5 hours, both SC or IV infusion.
Effect Of G-CSF on Endometrium
- In endometrium G-CSF is secreted apically in polarized epithelial cells
- G-CSF has been proposed as a treatment for implantation failure and repeated miscarriages.
- A growth support in endometrial thickness can be observed within 48 hours of G-CSF administration.
1.Ovulation indication , trigger with hcg 10,000 IU :>=1 Follicle >=19mm
2.Diagnosis of unresponsive thin endometrium :<7mm by ultrasound on the day of Hcg administration.
3.G-CSF Endometrial Infusion: 300mcg/1ml (Filgastrim) approximately 6-12 hrs before Hcg administration and Repeated G-CSF infusion if endometrium <7mm on day of ovum pickup
Usage in IUI:
- Ovulation induction with CC or Gonadotropins
- Hcg 10,000 IU >=1 Follicle >=20mm
- Diagnosis of unresponsive thin endometrium <7mm by ultrasound on the day of hcg administration.
- G-CSF endometrial infusion:300mcg/1ml approximately6-12hrs before hcg administration
- Endometrium has been documented to grow between 1-4mm after the infusion
- Can be given both intrauterine and subcutaneously and also Intravenously[if being used iv to be diluted only in 5% dextrose and never in saline]
- Is given with 1ml insulin syringe 6-12 hrs before Hcg administration.
- Comes as 300mcg/ml
`Growth spurt in endometrial thickness can be observed within 48 hrs of GCSFadministration.
Evaluation of GCSF in thin endometrium:
- For the treatment of thin endometrium
- Treatment option in patients with recurrent miscarriage.
- In Repeated embryo implantation failures in IVF.
- G-CSF plays an important role in reproductive functions like ovulation and embryo implantation
- Infertile women with persistently thin endometrium may benefit from G-CSF
- Effective in Treatment of Unexplained RM and RIF.