#292 : Combination of Hormone Replacement Therapy and Ovarian Stimulation as Endometrial Preparation Strategy for Refractory Thin Endometrium

Abstract

Background and Aims: The aim of the case study is to demonstrate that combination of hormone replacement therapy with controlled ovarian stimulation is effective to improve endometrial thickness (ET) in difficult cases of thin endometrium. Method: The patient is a 35-year-old, nulliparous with primary subfertility for six years. She had PCOS with history of right salphingo-oophorectomy done for benign serous papillary cystadenoma. The male partner had severe oligoasthenoteratozoospermia. He started on FSH injections for three months with slight improvement in sperm parameters. She then underwent an IVF cycle and obtained five blastocysts. We struggled with thin ET with one failed frozen embryo transfer (FET) and two abandoned cycles. The patient was started with hormone replacement therapy on day one menses with tablet progynova 4 mg six hourly together with estrogel 3 g eight hourly transdermally. A scan was performed on day one menses and endometrial thickness was 4.5 mm. The serum progesterone and luteinizing hormone was baseline. A repeat scan for ET was done on day seven menses and was noted to be 6.4 mm. She was given another four days of oral and transdermal estrogen and the ET remained 6.4 mm at day eleven menses. We decided to perform low dose ovarian stimulation with recombinant FSH 150 IU daily. She was then seen on day fourteen menses for repeat scan. The ET only marginally increased to 6.7 mm. We increased the injection to 225 IU daily. On day eighteen menses, her ET was 7.8 mm and we triggered with HCG 5000 IU. She had her FET done on day twenty-five menses. Results: Her BHCG two weeks later was 948.3 U/L. The pregnancy is currently ongoing at 18 weeks. Conclusion: A combination of hormone replacement therapy and ovarian stimulation enables the exogenous and endogenous estrogen to act synchronously on the endometrium to achieve better endometrial thickness for implantation.