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Fertility add-on · Evidence review · UK

Endometrial scratch before IVF, the honest evidence.

A Pipelle biopsy of the endometrium in the cycle before embryo transfer, in the hope that a small controlled injury releases cytokines and helps implantation. The landmark SCRATCH trial (Lensen 2019, NEJM, 1,364 women) showed no improvement in live birth over usual care. That is worth knowing, and it is worth discussing what actually might help.

A stethoscope on a clinical desk

The evidence, in one line

SCRATCH (Lensen, NEJM 2019, n=1,364): live birth 26% with scratch, 26% without. HFEA, ESHRE and ASRM now advise against routine use.

Earlier smaller trials suggested a benefit and are the reason the procedure spread through private clinics. The largest and best-designed trial refuted them. Where a scratch is still discussed at all, it is only in highly selected recurrent implantation failure, after other causes have been ruled out, and with fully informed consent about the lack of evidence.

Indicative pricing

What a scratch costs, and what would be a better spend.

Because the evidence for scratch is weak, it is often better to spend the same money on a proper cavity assessment or endometritis screen.

Option Indicative range
Endometrial scratch (Pipelle biopsy alone) £280–£450
Scratch as an add-on to a baseline or mock cycle scan £180–£280
Saline infusion sonohysterography (cavity assessment) £350–£600
Outpatient hysteroscopy with directed biopsy £1,200–£2,400
Recurrent implantation failure workup (bundled) £1,500–£3,500
Second-opinion review of your IVF notes £250–£450

London providers offering the procedure include The Lister Fertility Clinic, CARE Fertility London, ARGC and TFP The Fertility Partnership. Ask any of them for the trial evidence they rely on before you consent.

When it is still discussed

The narrow window where scratch may still be considered.

None of these are recommendations. They are the only settings where a considered discussion still happens, and always with informed consent about the lack of evidence.

  • One or more failed IVF transfers of good-quality embryos

    Sometimes still discussed, in a highly selected setting, after cavity and endometritis have been excluded.

  • Patient specifically requesting scratch

    Common online reading has entrenched the idea.

  • Before a fresh or frozen transfer

    If offered at all, timed to the mid to late luteal phase of the cycle before the planned embryo transfer.

  • When scratch is not appropriate

    First IVF cycle, active pelvic infection, pregnancy, an untreated cavity abnormality, or an unexplored underlying cause.

Better places to spend the money

What actually addresses recurrent implantation failure.

A structured workup finds treatable causes. Any single one of these has more mechanistic support than an endometrial scratch.

  • Uterine cavity assessment first

    Saline infusion sonohysterography or outpatient hysteroscopy finds polyps, fibroids, adhesions and septa - real and treatable causes of failed implantation.

  • Chronic endometritis screening

    CD138 immunohistochemistry on an endometrial biopsy identifies low-grade endometrial infection, which responds to a course of antibiotics.

  • Thyroid and prolactin

    TSH, free T4, thyroid antibodies and prolactin. Cheap, quick, and correcting them changes outcomes more reliably than a scratch.

  • PGT-A for aneuploidy

    Preimplantation genetic testing for aneuploidy reduces transfer of chromosomally abnormal embryos - the largest single driver of implantation failure over 35.

  • Thin endometrium interventions

    Extended oestradiol, vaginal sildenafil (Viagra), G-CSF instillation and platelet-rich plasma for a lining that will not build - evidence varies, but each has more mechanistic support than a scratch.

  • Sperm DNA fragmentation

    A high DNA fragmentation index is under-recognised in unexplained failure. Correcting it with lifestyle, antioxidants or surgical retrieval can change results.

  • ERA endometrial receptivity

    Molecular timing of the window of implantation - useful in selected cases where the histology and hormones look normal but transfers still fail.

  • Immunological workup

    Reserved for recurrent pregnancy loss and highly selected recurrent implantation failure - antiphospholipid, thrombophilia, and thyroid autoimmunity.

The procedure, if you proceed

From appointment to Pipelle - what happens, in order.

A single outpatient visit timed to the cycle before your planned transfer. Around ten minutes in the room.

  1. 03

    Before

    You choose - with the evidence in front of you

    A written summary of what SCRATCH showed, what the older trials showed, and the current HFEA, ESHRE and ASRM positions. No pressure either way.

  2. 04

    On the day

    A short outpatient visit

    Timed to the luteal phase of the cycle before transfer. Paracetamol or an NSAID an hour beforehand. Around 10 minutes in the room.

  3. 05

    On the day

    The scratch itself

    Speculum, sometimes a tenaculum, and a Pipelle catheter passed to the fundus. Ten to thirty seconds of insertion and rotation to sample endometrium. Cramping like a heavy period.

  4. 06

    After

    Home the same day

    Light bleeding for one to three days. Normal activity that afternoon. Your IVF cycle proceeds on its planned schedule.

What to look for in a clinic

HFEA-licensed clinics, honest about add-ons.

  • HFEA-licensed clinics with named fertility consultants, not add-on lists

  • Evidence-based practice - scratch discussed with SCRATCH trial data upfront

  • Full recurrent implantation failure workup available in the same clinic

  • No pressure to buy add-ons the HFEA rates amber or red

Safety and recovery

What to expect on the day - honestly.

The procedure itself is safe and short. The bigger question, always, is whether it is worth doing at all.

  • Cramping like a heavy period

    The main sensation during and for a few hours after. An NSAID an hour beforehand helps most patients.

  • Light bleeding for one to three days

    Spotting or a light bleed is normal. Heavy bleeding, fever or offensive discharge should prompt a call to the clinic.

  • Infection is uncommon

    Around 1 in 200 procedures. Prophylactic antibiotics are not routine, but any post-procedure fever needs assessment.

  • Vasovagal reaction

    A short faint or wave of nausea during instrumentation is not unusual. You are watched for a few minutes before you leave.

  • Pregnancy must be excluded

    A urine or blood pregnancy test is done on the day. A scratch is never performed if there is any chance of an existing pregnancy.

  • Cycle timing matters

    Performed in the mid to late luteal phase of the cycle immediately before the planned embryo transfer, not the transfer cycle itself.

Reading your procedure note

Your scratch note in four parts. Read the last one first.

A well-written note records that the SCRATCH trial evidence was discussed and that you consented on that basis. If it does not, ask the clinic to add it.

  1. 01 Header

    Date, cycle day and indication

    When the procedure was done, the day of your cycle, and the reason given (patient request, recurrent implantation failure, clinician preference).

  2. 02 Technique

    Pipelle passage and sampling

    Whether the catheter passed easily, how many passes, and whether a tenaculum was needed. Discomfort score is noted.

  3. 03 Findings

    Sample adequacy

    Whether the tissue collected was enough for histology if CD138 endometritis screening was requested at the same time.

  4. 04 Impression

    Evidence discussion recorded

    Read this first. Should record that the SCRATCH trial (Lensen 2019) showed no live-birth benefit, and that you consented on that basis.

Recognised by major UK insurers

BupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealix

IVF and its add-ons are almost never covered by private medical insurance. Endometrial scratch is self-pay.

Frequently asked

Common questions about endometrial scratch.

Quick answers on the SCRATCH trial, evidence, insurance and better alternatives.

  • What did the SCRATCH trial actually show?

    The SCRATCH trial (Lensen et al., New England Journal of Medicine, 2019) randomised 1,364 women undergoing IVF to endometrial scratch or usual care. Live birth rates were 26% in each arm - no benefit at all. It is the largest and best-designed trial to date, and it has led the HFEA, ESHRE and ASRM to advise against routine use.

  • Is there any evidence that scratch helps anyone?

    The earlier positive trials were smaller, methodologically weaker and subject to publication bias. Subgroup analyses since SCRATCH have not identified a group of patients who reliably benefit. If a clinic offers scratch, the honest position is that any benefit is unproven, even in recurrent implantation failure.

  • Will my insurer pay for it?

    No UK insurer routinely funds endometrial scratch, because it is not evidence-based and is classed as an IVF add-on. IVF itself is not usually covered by private medical insurance either. This is a self-pay procedure.

  • What should I do instead if my IVF cycles are failing?

    Ask for a proper recurrent implantation failure workup: cavity assessment with saline infusion sonohysterography or hysteroscopy, chronic endometritis screening, thyroid and prolactin, sperm DNA fragmentation, and a discussion of PGT-A. Any one of these is more likely to change your outcome than a scratch.

  • What counts as recurrent implantation failure?

    There is no single accepted definition. Most centres use two or three failed transfers of good-quality embryos in a woman under 40, or the transfer of at least four good-quality embryos in total, before labelling implantation failure and starting a detailed workup.

  • Do UK fertility clinics still offer scratch?

    Some do, usually as a patient-requested add-on. The HFEA rates endometrial scratch amber for most patients and red for first IVF cycles, meaning there is not enough evidence to recommend it. If a clinic recommends it as a matter of routine, that is a reason to ask for a second opinion.

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