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Short-term Benefits of Endometrial Biopsy are Similar to Diagnostic Laparoscopy for Unexplained Infertility Paul B. Miller, MD1, Lauren M. O’Donnell2, Creighton E. Likes, MD1, David A. Forstein, DO1, William E. Roudebush, PhD1, and Bruce A. Lessey, MD, PhD1 1Department 2Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Greenville Health System, Greenville, SC, USA of Microbiology, Clemson University, Clemson, SC, USA Introduction Results Endometrial injury (“scratching”) has been reported to improve pregnancy rates in women with infertility. The objective of this study was to specifically examine the effect of endometrial biopsy (EMB) on couples with unexplained infertility (UI) and compare their time to pregnancy versus those who underwent laparoscopy (LS). 334 subjects with unexplained infertility Results Figure 1: Kaplan Meier life tables comparing pregnancy rates among 3 groups A. Unadjusted 116 subjects Incomplete data, lost to follow up, not truly unexplained Group 218 participants Control Biopsy Laparoscopy Methods • • Study design: retrospective cohort study All patients enrolled at a tertiary care fertility center with UI from January 2005 – October 2014 Inclusion: • Documented ovulatory cycles • Normal pelvic sonogram • At least one patent tube on HSG or LS • Partner with normal or mildly irregular semen analysis Exclusion: • Irregular cycles • BMI ≥ 40 kg/m2 • Age > 39 • Moderate to severe male factor • IVF within 6 months of intervention (EMB or LS) Post-intervention Cycles: • All subsequent cycles were either natural, treated with clomiphene citrate or letrozole alone, or combined with gonadotropins Statistical methods: • Parametric and non-parametric data were analyzed using ANOVA and Kruskal-Wallis tests, respectively • Pregnancy rates were analyzed over time using Kaplan-Meier survival tables 93 controls 58 biopsied 67 laparoscopy Table 1: Baseline demographics Characteristic Age (years) BMI (kg/m2) Gravidity Parity Protocol [n(%)] Natural Clomiphene/Letrozole Clomiphene+hMG Letrozole+hMG Control N=93 Biopsy N=58 Laparoscopy N=67 P 31.4 (3.6) 22.9 (20.7-25.2) 1 (0-1) 0 (0-1) 33.4 (3.5) 23.1 (21.4-26.6) 1 (0.75-2) 0 (0-1) 31.3 (3.6) 23.5 (20.9-25.6) 1 (0-1) 0 (0-1) 0.001a 0.5b 9 (10) 67 (72) 9 (10) 8 (8) 6 (10) 45 (78) 2 (3) 5 (9) 9 (13) 56 (84) 0 (0) 2 (3) B. Adjusted for covariables (Cox regression) Group Control Biopsy 0.002b 0.02b Laparoscopy 0.08c Numbers are mean (SD) or median (25th-75th percentile) aANOVA; bKruskal-Wallis; cChi-square for trend Table 2: Variables in Cox proportional hazards regression Variable Age BMI Gravidity Parity Control Biopsy Laparoscopy Hazard Ratio 95% CI P 1.04 0.9 1.26 0.7 1 2.64 3.92 0.98-1.1 0.93-1.04 1.02-1.56 0.51-1.23 0.1 0.6 0.031 0.3 1.38-5.05 2.11-7.28 0.003 0.0001 Conclusions • • EMB improves pregnancy rates in women with unexplained infertility undergoing treatment with ovulation induction Mechanical injury of the endometrium at the time of laparoscopy may account for some of the benefit of surgery on fecundity