Physician-To-Physician Consult

Dear Colleague,

We have had several cases of patients who develop endometrial fluid during IVF cycles as well as frozen embryo transfer cycles using estrogen stimulation and even natural cycle attempts at frozen embryo transfer, and we do not do an embryo transfer. Work ups have included US showing no visible hydros, HSG showing no hydros and office hysteroscopy showing normal cavity. This is not common but a challenge We do not want to place fresh or frozen embryos into a 'swimming pool' so to speak as pregnancy rates are low in the presence of endometrial cavity fluid.
What have others done?


Ellen M Greenblatt, MD, FRCSC; FACOG (REI)
Medical Director Centre for Fertility and Reproductive Health
Mount Sinai Hospital,
Associate Professor University of Toronto

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Answer by Norbert Gleicher

Hi Everybody,
First of all "fluid" often is not fluid; it more often than not is thick mucus when aspirated. Indeed, often it is so thick that it becomes difficult to aspirate. Moreover if you aspirate, it usually comes back quickly.
Second, we usually see this accompanied by relatively thin endometria.
Here is what we do: (1) Try to aspirate the mucus; (2) Do a slow endometrial "perfusion" with 1 ampule of Nupogen (G-CSF, Filgastrim). G-CSF dilutes the remaining mucus, and in our experience, prevents it from reaccumulating.
Good Luck

Norbert Gleicher, MD

Medical Director and Chief Scientist, The CHR
President, Foundation for Reproductive Medicine

Answer by Shlomo Mashiach

I agree with Norbert that the "fluid" is in fact mucous. I see it quiet frequently in women that had Cesarian Section in a previous pregnancy. In these patients a careful hysteroscopy with a special attention to the cervix or isthmus demonstrates, very often, a "niche" which is the source of the mucous. The mucous in the endometrial cavity might be the main cause of infertility. We have treated these cases with an hysteroscopic ablation of the endocervical mucous with a high success rate (pregnancies both spontaneous or after ART).

Shlomo Mashiach

Answer by paul claman

We try to aspirate fluid at time of ET and if it is easy we go ahead with ET.  If \"fluid\" is thicker and cant be aspirated will suggest freezing embryo for later transfer.  In general we don\'t find the problem is recurrent.  I thank Dr.Mashiach for suggestion of HSCOPE resection of mucus producing cervical crypts in cases when this occurs on repeat cycles.

paul claman MD

Ottawa Fertility Centre

Answer by Joel Bernstein

Dear Colleagues

I have noted the presence of \"fluid\" which appears to occur with patients on our donor egg programmes who are on Hormone Replacement Therapy. In the few cases we have had it appears while they are on Oestrogen replacement (oestradiol valerate) however has disappeared after 2-3 days of progesterone supplementation and in all these cases embryo transfer occurred and this has not affected our pregnancy rate. Suggest a trial ongoing ultrasound monitoring of your patients cycle into the progesterone phase.

Joel Bernstein

Fertilityeast Sydney Australia

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