**6.5. Hysteroscopic site-specific endometrial injury (49)**

A site-specific hysteroscopic biopsy-induced injury of the endometrium during the controlled ovarian hyperstimulation cycle has been shown to improve subsequent embryo implantation in patients with repeated implantation failure. The procedure starts with performing panoramic hysteroscopy. A flexible claw forceps is introduced through a 2.2 mm working channel which is used to generate a local injury on the posterior endometrium at midline 10-15 mm from the fundus on D4 to D7 of the stimulation cycle. The depth and width of the injured site is 2 × 2 mm (i.e. a bite of the claw forceps). No antibiotic or hemostatic drug is administered after the procedure.

Endometrial injury may have a beneficial role in implantation and improve the pregnancy rate. However, there are still many unanswered question including patients selection, timing, technique and number of endometrial biopsies needed (50).
