Endometrial Scratching Before IVF: Why It Is No Longer a Routine Add-On
Key Takeaways
Endometrial scratching was once promoted as a way to improve implantation, but large reviews now show little or no meaningful benefit for most IVF patients. It may still come up after repeated failures, yet it should not be treated as a routine add-on before transfer. If it is being recommended, ask what evidence supports it in your specific case.
Key evidence: ESHRE 2023 — add-ons in reproductive medicine ESHRE 2023 — recurrent implantation failure recommendations Cochrane 2021 — endometrial injury in assisted reproduction
On this page
- What the procedure is
- Why the idea became popular
- What the evidence shows
- Use after repeated implantation failure
- Pain and risks
- Use before a first IVF cycle
- FAQ
- Clinical note
- Sources
Endometrial scratching, also called endometrial injury, once seemed like a simple way to help implantation during IVF. The idea was easy to understand: a small procedure, a plausible biological theory, and the hope of improving the next transfer.
Better studies have since changed the conversation. They have not shown a reliable improvement in live birth for most patients. ESHRE therefore does not recommend endometrial scratching as a routine IVF add-on.
What the Procedure Actually Is
Endometrial scratching usually means creating a small intentional injury in the uterine lining, often with a pipelle-like instrument, in the cycle before embryo transfer.
The procedure is not complex, but it is still an invasive step. It can cause:
- cramping,
- light bleeding,
- anxiety around timing,
- and, when hysteroscopy is used, a small risk of infection.
These effects are usually limited, but they still matter when the expected benefit is uncertain. Even a minor procedure needs a clear reason.
Why the Idea Was So Popular
The original theory was that a small injury might trigger a local repair response and make the endometrium more receptive. Researchers proposed several possible mechanisms:
- inflammatory signaling,
- growth factor release,
- changes in gene expression,
- or improved synchronization between embryo and endometrium.
These mechanisms sounded biologically interesting, but biologic plausibility is not the same thing as a proven clinical benefit.
What the Evidence Shows Now
This is where the early promise ran into stronger evidence. The 2021 Cochrane review and ESHRE’s 2023 add-on recommendations do not support routine use.
The most practical conclusion is:
- it does not clearly improve live birth in most IVF patients,
- it should not be added automatically before a first cycle,
- and even after previous failures, the evidence remains weak.
Some smaller studies have suggested a benefit. Taken together, however, the strongest evidence does not show that routine scratching meaningfully improves outcomes.
Does It Help After Repeated Implantation Failure?
This is when scratching is most likely to be mentioned. After another unsuccessful transfer, it is understandable to ask whether one more test or procedure might make the difference.
But current data still do not show a reliable benefit even in that group. ESHRE’s recommendations on recurrent implantation failure state that intentional endometrial injury is not recommended.
The wish to “try something extra” is understandable. But a procedure with uncertain benefit can distract from a more useful review of:
- embryo quality,
- uterine cavity problems,
- the timing and duration of progesterone in a programmed transfer cycle,
- or the larger fertility diagnosis.
Is It Painful or Risky?
Patients often describe the procedure as a strong cramp or an uncomfortable biopsy. Some tolerate it well. Others find it more difficult than expected, particularly when they later learn that the benefit is uncertain.
Possible downsides include:
- pelvic pain during or after the procedure,
- light to moderate bleeding,
- scheduling inconvenience,
- and a small infection risk when the procedure is performed by hysteroscopy.
When benefit is uncertain, even minor risk and discomfort start to matter more.
Should It Be Done Before a First IVF Cycle?
For most patients, no.
This is one of the clearest conclusions in the evidence. Endometrial scratching should not be presented as a standard step before a first IVF attempt.
The first IVF cycle is already demanding. Adding an unproven invasive procedure usually creates more burden, not more certainty.
Related Reading
- Fresh vs Frozen Embryo Transfer: How Doctors Usually Choose
- After Embryo Transfer: Practical Guidance for the Two-Week Wait
- Preparing the Endometrium for Frozen Embryo Transfer: HRT, Natural, and Hybrid Cycles
FAQ
Does endometrial scratching improve pregnancy rates in IVF?
Current evidence does not show a reliable improvement in live birth or clinical pregnancy for most patients.
Is endometrial scratching still recommended routinely?
No. It is no longer considered a routine IVF add-on.
Can it still be discussed after repeated failures?
Yes, it may still come up in conversation, but repeated failure does not automatically make it evidence-based or necessary.
Is the procedure harmless if I want to try everything?
Not completely. It is still an invasive step with discomfort and a small risk profile, so it should not be treated like a meaningless extra.
Endometrial scratching shows why a plausible idea still needs strong outcome data. The theory was attractive. However, the clinical benefit has not held up well enough to justify routine use.
For most patients, it is better to focus on embryo quality, uterine assessment, transfer timing, and individualized IVF planning. Scratching should not be added by default.
Clinical Note
I do not use endometrial scratching as a routine step before IVF or after a fixed number of failed transfers. A failed transfer deserves a review of the embryo, uterine cavity, transfer conditions, and—when relevant—the timing of progesterone exposure. It does not automatically create an indication for another invasive procedure.
Dr. Senai Aksoy
Sources
- Cochrane Review on endometrial injury in women undergoing assisted reproduction
- Multicenter trial on endometrial scratching before IVF
- Meta-analysis on endometrial scratching after repeated implantation failure
- Review on timing and number of endometrial injury procedures
- Systematic reviews referenced in later evidence summaries
- ESHRE good practice recommendations on add-ons in reproductive medicine
- ESHRE good practice recommendations on recurrent implantation failure
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The content has been created by Dr. Senai Aksoy and medically approved.