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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 4  |  Page : 240-241

Tamoxifen in recurrent thin endometrium


Department of Reproductive Medicine and Surgery, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Web Publication5-Dec-2018

Correspondence Address:
Abdul Basith S. Fazal
9, New No: 4, Barnaby Avenue, Kilpauk, Chennai - 600 010, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_57_18

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  Abstract 


To evaluate the effects of tamoxifen in patients with repeated unresponsive thin endometrium (<6 mm). Three women showed recurrent thin endometrium <6 mm during frozen embryo transfer endometrial preparation. Tamoxifen was added in the successive cycles as an adjunct. The endometrium was found to build up more than the target 7 mm in all the women with tamoxifen therapy. Two of the women conceived. In frozen-thawed embryo transfer cycles with recurrent thin endometrium, addition of tamoxifen helps achieve target endometrial thickness.

Keywords: Frozen embryo transfer, hysteroscopy, in vitro fertilization, recurrent thin endometrium


How to cite this article:
S. Fazal AB, Munjal R, Kirthika K S. Tamoxifen in recurrent thin endometrium. Apollo Med 2018;15:240-1

How to cite this URL:
S. Fazal AB, Munjal R, Kirthika K S. Tamoxifen in recurrent thin endometrium. Apollo Med [serial online] 2018 [cited 2018 Dec 15];15:240-1. Available from: http://www.apollomedicine.org/text.asp?2018/15/4/240/246890




  Introduction Top


The probability of pregnancy in vitro fertilization (IVF) cycles is highest when endometrium is between 7 and 14 mm.[1] The number of patients who achieve suboptimal endometrial thickness ranges from 1% to 10%. This can lead to cycle cancellation and difficult emotional counseling sessions. It is distressing for the patient and the doctor. When no cause is found for a recurrent thin endometrium after initial evaluation, there are a few limited options to increase the thickness in subsequent cycles. One such novel option is tamoxifen.


  Case Reports Top


Case 1

Mrs. G was anxious to conceive for the past 8 years. She was a nullipara, with cycle duration and frequency of 3 days/6 months and normal flow. She did not have any medical illness nor past surgeries. Her hormonal profile was as follows: follicle-stimulating hormone: 22, luteinizing hormone: 11, estradiol (E2): 32, and anti-Mullerian hormone: 0.19, and scan revealed an antral follicle count of very few follicles.

The semen analysis was 44 million/ml with motility 60% and 50% normal morphology. We went ahead with donor oocyte and intracytoplasmic sperm injection (ICSI). Direct hormone replacement therapy (HRT) was used to prepare the recipient endometrium. Recipient endometrium was not responsive to estradiol valerate at a maximum dose in oral, vaginal, and transdermal route. Adjunctive treatments such as low-dose aspirin, sildenafil, and vitamin E were used. Concurrent transfer was canceled. We proceeded with a diagnostic hysteroscopy and tuberculosis testing which came out as normal.

In the subsequent cycle, the patient was started on tablet tamoxifen 20 mg BD for 10 days. After endometrial thickness of 6 mm was reached, tablet estradiol valerate was started and a maximum endometrial thickness of 8.5 mm was achieved. Following progesterone +2 days, embryo transfer was done. Clinical pregnancy was established. Currently, this is an ongoing pregnancy.

Case 2

36 year old Mrs. C presented, presented with frozen embryos after ICSI done for severe male factor. Previously, downregulated HRT and stimulated cycles did not grow endometrium more than 4 mm. Adjunctive treatment was used with both endometrial preparations. Evaluation of the cavity and endometrium was normal. It was decided to use tablet tamoxifen 20 mg BD in the subsequent cycle. After 8 days of tamoxifen, endometrium grew up to 7 mm. Tablet estradiol valerate was started, and after a maximal dose, endometrium grew to 9 mm.

Embryo transfer was done and clinical pregnancy established thereafter. It is an ongoing pregnancy currently.

Case 3

Mrs. A, a 32-year-old woman, presented with hypo-oligomenorrhea with a history of repeated curettage. Saline sonohysterography was normal. ICSI was done for failed ovulation induction + intrauterine insemination >6 cycles, long period of infertility. Embryos were frozen. Stimulated cycle endometrium was 5 mm. Hysteroscopy revealed intrauterine adhesions. Adhesiolysis was done and cyclical estradiol valerate and medroxyprogesterone withdrawal for 3 months were prescribed.

Relook hysteroscopy showed minimal adhesions which were lysed. Subsequently, the patient was started on tablet tamoxifen and endometrium grew to 5 mm. Then, tablet estradiol valerate was started which was continued for 14 days, and endometrium grew up to 7 mm. Embryo transfer was done. Pregnancy test was negative.


  Discussion Top


Our case series of three IVF patients with recurrent thin endometrium were subjected to tablet tamoxifen after ruling out other possible causes of thin endometrium.

Tamoxifen is a nonsteroidal selective estrogen receptor modulator. The action of tamoxifen depends on the target organ. Its antiestrogenic action on the breast has long since been used in the prevention of recurrence of breast cancer. One of the adverse effects of the use of tamoxifen is the proestrogenic/progestogenic effect on the endometrium which causes endometrial hyperplasia/endometrial cancer in women with prolonged use. This is independent of folliculogenesis leading to steroid production. It is due to the direct effect on the endometrium since the majority of women who use it are post menopausal. Tamoxifen is said to increase the local estrogen biosynthesis by inducing transcription factor that induces aromatase production. It is also said to act via upregulating the insulin-like growth factor-1 expression.[2] The half-life is 85 h and there is no higher risk of teratogenic effects.[3] Tamoxifen 20 mg tablet was used twice daily for a maximum of 10 days for the above three patients.

When other options have been exhausted, tamoxifen was used in recurrent thin endometrium.

All the three women grew the target endometrial thickness (7 mm) and two out of three women conceived. However, this is a preliminary study and further randomized trials are necessary to prove the effect of tamoxifen on thin endometrium.


  Conclusion Top


Tamoxifen is a viable option to treat recurrent thin endometrium to optimize IVF outcomes. Further trials involving larger number of patients are necessary before it could be adopted routinely into clinical practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Richter KS, Bugge KR, Bromer JG, Levy MJ. Relationship between endometrial thickness and embryo implantation, based on 1,294 cycles of in vitro fertilization with transfer of two blastocyst-stage embryos. Fertil Steril 2007;87:53-9.  Back to cited text no. 1
    
2.
Williams-Brown MY, Salih SM, Xu X, Veenstra TD, Saeed M, Theiler SK, et al. The effect of tamoxifen and raloxifene on estrogen metabolism and endometrial cancer risk. J Steroid Biochem Mol Biol 2011;126:78-86.  Back to cited text no. 2
    
3.
Berger JC, Clericuzio CL. Pierre robin sequence associated with first trimester fetal tamoxifen exposure. Am J Med Genet A 2008;146A: 2141-4.  Back to cited text no. 3
    




 

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