A new role for natural killer cells, interleukin (IL)-12, and IL-18 in repeated implantation failure after in vitro fertilization

OBJECTIVE

To investigate the endometrial immunohistochemical staining of interleukin (IL)-12 and IL-18 and to quantify the CD56 bright natural killer (NK) cells in relation to Doppler vascular disorders.

DESIGN

Controlled clinical study.

SETTING

Research unit of a university hospital. PATIENT(S)": Thirty-five women with repeated implantation failure after ET in IVF and 12 fertile control patients.Ultrasound evaluation and endometrial biopsy on day 20.

MAIN OUTCOME MEASURE(S)

The balance between IL-12 and IL-18, the number of NK cells, and the vascular status among fertile and implantation failure patients.

RESULT(S)

The control patients displayed normal vascular parameters, a weak anti-IL-12 staining, a consistent moderate stromal anti-IL-18 staining, and fewer than 15 NK cells/field. This pattern was observed among only 17% (6/35) of the implantation failure group. The remaining patients fit into one of two patterns: [1] 37% (13/35) had more than 40 NK cells/field with a strong anti-IL-12 and/or anti-IL-18 staining, and [2] the remaining 46% (16/35) had a marked local depletion of IL-18 and IL-12. Respectively, 85% and 31% of two groups displayed abnormal vascular parameters.

CONCLUSION(S)

Distinctions between the different local dysregulations of the cytokine network may provide clues for further exploration and treatment.

Role of routine ultrasonography in monitoring the outcome of medical abortion in a clinical setting

BACKGROUND

Clinical methods generally used to evaluate the completeness of medical abortion are not accurate. There are no published reports evaluating the role of routine ultrasonography in monitoring the outcome of medical abortion. The purpose of this study was to investigate whether routine transvaginal ultrasonography (TVS) at the follow-up visit after medical abortion can accurately identify women who will require surgical intervention.

DESIGN

Retrospective review of medical records and charts of all women undergoing medical abortion in the first trimester of pregnancy between January 1999 and December 2001.

METHODS

Medical abortion was performed using oral mifepristone and a vaginal prostaglandin analog before 63 days gestation. All women had an initial TVS to confirm intrauterine pregnancy and gestational age, and another TVS at the follow-up visit 2-3 weeks later to assess the completeness of abortion. Surgical evacuation of the uterus was allowed as indicated on clinical grounds but not on the basis of ultrasound findings only.

RESULTS

A total of 690 women consented to medical abortion during the study period. Eleven of these women were excluded from the study for various reasons. Of the remaining 679 cases, 95% (645/679) had a documented follow-up at the hospital. The pregnancy termination rate among these women was 99.2% (640/645) and TVS identified all five cases of continuing pregnancy at the follow-up. A total of 66 (10.2%) patients had complications. The uterine cavity was empty on TVS at the follow-up visit in 84.8% (547/645) of cases and only 3.1% (17/547) of them required surgical aspiration/curettage due to excessive or prolonged vaginal bleeding. In the remaining 15.2% (98/645) the uterine cavity was not empty, and 43.9% (43/98) of them had a curettage. The risk of requiring a surgical intervention was significantly higher [odds ratio (OR) 24.4; 95% confidence interval (95% CI) 14.9-39.7] when the uterine cavity was not demonstrated to be empty at the follow-up visit 2-3 weeks after medical abortion. However, 59.1% (55/93) of women did not require surgical intervention despite ultrasound evidence of thick endometrial echo-complex.

CONCLUSION

Routine TVS 2-3 weeks after medical abortion appears to be an efficient means of accurately identifying the cases of ongoing pregnancy and diagnosing a complete abortion. Although TVS could be used as an adjunct to clinical examination to diagnose an incomplete expulsion, it does not accurately differentiate those women who require surgical intervention from those who do not.

Sonohysterography: a valuable tool in evaluating the female pelvis

A number of medical conditions, including abnormal uterine bleeding, endometrial cancer, monitoring tamoxifen therapy, infertility, and recurrent abortion, warrant investigation of the female genital tract. Diagnostic studies including hysterosalpingogram, ultrasound, and sonohysterography have proved useful in the investigation of these gynecologic conditions. This article discusses each of these tests with particular emphasis on sonohysterography and their current and potential contributions in both diagnostic and therapeutic applications. The utility of each as well as their comparative value to each other and existing gold standards is reviewed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to outline the current screening methods for uterine cavity and pelvic abnormalities, to list the advantages of sonohysterography, and to describe the clinical situations where sonohysterography can be used.

Uterine contractility and directed sperm transport assessed by hysterosalpingoscintigraphy (HSSG) and intrauterine pressure (IUP) measurement

BACKGROUND

Uterine peristalsis sustains sperm transport and can be detected by hysterosalpingoscintigraphy (HSSG). This study is the first to be designed to investigate utero-tubal transport function by HSSG and uterine contractility by intrauterine pressure measurement (IUP) consecutively on the same day in the periovulatory phase.

METHODS

Twenty-one female subjects (mean age 28.4 years) without a gynecologic history were examined sequentially by HSSG and IUP on the same day to evaluate uterine contractility in relation to the utero-tubal transport function. In HSSG, intact transport function was visualized by the rapid uptake of 99m-technetium-marked albumin aggregates through the female genital tract. In IUP, the frequency of uterine contractions (UC/min), amplitude of uterine contractions and basal pressure tone were detected via a intrauterine catheter. HSSG and IUP were embedded in cycle monitoring with measurement of LH and estradiol.

RESULTS

In HSSG, a positive transport of inert particles was assessed in 20 of 21 subjects, in 76% to the side of the dominant follicle or on both sides of the oviduct, and in 19% a strict contralateral transport could be observed. In only one subject (5%), no transport was assessed. The mean value of uterine contractions was 3.4 UC/min (SD +/- 0.7), the mean amplitude was 12.0 mmHg (SD +/- 4.25 mmHg). Basal pressure tone was 70.7 mmHg. There was a statistically significant correlation with estradiol levels: none of the subjects with less than 3 UC/min showed an estradiol level higher than 100 pg/mL; nearly every patient (one exception) with more than 3 UC/min had an estradiol level higher than 100 pg/mL (p < 0.0001, Fisher's exact test).

CONCLUSIONS

Intact periovulatory utero-tubal transport function can be documented by HSSG and is caused by directed uterine contractility, measured consecutively by IUP. Uterine contractility is influenced by rising estradiol levels. Directed uterine contractility and intact utero-tubal transport function are considered necessary for intact sperm transport, mainly to the side bearing the dominant follicle to maximize fertility.

Raloxifene therapy does not affect uterine blood flow in postmenopausal women: a transvaginal Doppler study

OBJECTIVE

To monitor the effects of raloxifene therapy on the uterus of postmenopausal women by transvaginal ultrasonography and color flow Doppler.

METHODS

Twenty-five healthy postmenopausal women were enrolled in this prospective longitudinal study performed at Department of Gynecology and Obstetrics, Faculty of Medicine of Ribeirão Preto. The patients were treated with raloxifene hydrochloride (60 mg per day) for 6 months. All were submitted to transvaginal ultrasound examination with color flow Doppler (ATL-HDI 3000 equipment) before the beginning and after 1, 3 and 6 months of treatment. Resistance index (RI) and pulsatility index (PI) of the uterine arteries were determined by the Doppler method, being considered as indicators of uterine perfusion. The following variables were analyzed: endometrial thickness, uterine volume, RI, and PI. Data were analyzed statistically by repeated-measures analysis of variance.

RESULTS

Before treatment, endometrial thickness was 3.38 +/- 0.73 mm, and similar values were observed after 1, 3 and 6 months of treatment (3.04 +/- 0.82; 3.3 +/- 0.83; and 3.37 +/- 0.79, respectively) (P > 0.05). No significant differences in uterine volume were observed between the pre- and post-treatment periods. Uterine artery perfusion as indicated by RI and PI measured by Doppler also showed no significant variation, with a high impedance flow being maintained throughout treatment.

CONCLUSIONS

In the group studied here, raloxifene treatment at the dose of 60 mg per day for 6 months did not induce significant changes in endometrial thickness, uterine volume or uterine artery perfusion, confirming that short-term raloxifene treatment does not affect the uterus of postmenopausal women.

Adjuvant low-dose aspirin therapy in poor responders undergoing in vitro fertilization: a prospective, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the effect of adjuvant low-dose aspirin on utero-ovarian blood flow and ovarian responsiveness in poor responders undergoing IVF.

DESIGN

Prospective randomized, double-blind, placebo-controlled study.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Sixty patients classified as poor responders undergoing IVF.

INTERVENTION(S)

Supplementation with low-dose aspirin (80 mg daily) or placebo to a long down-regulation protocol.

MAIN OUTCOME MEASURE(S)

Doppler measurement of intraovarian and uterine pulsatility index was performed before (baseline) and after ovarian stimulation (day of hCG administration). Duration of use and dose of gonadotropins, cycle cancellation rate, number of mature follicles recruited, and oocytes retrieved were also measured.

RESULT(S)

High cancellation rates were found in both groups (33.3% vs. 26.7%, placebo vs. treatment). There were no significant differences in total dose of hMG used (66 vs. 57 hMG, 75 IU ampules), median number of mature follicles recruited (3.5 vs. 3.0), or median number of oocytes retrieved (4 vs. 3). No significant differences were found in either intraovarian or uterine artery pulsatility index measured at baseline or on the day of hCG administration.

CONCLUSION(S)

Supplementation with low-dose aspirin failed to improve either ovarian and uterine blood flow or ovarian responsiveness in poor responders undergoing IVF.

Role of sonography in the diagnosis of retained products of conception

OBJECTIVE

To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings.

METHODS

This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty-one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor.

RESULTS

Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false-positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false-positive rates were 28.9% and 51.5%, respectively.

CONCLUSIONS

Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false-positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Uterine doughnut in early proliferating phase: potential pitfall in gastrointestinal bleeding studies

A 41-year-old woman with rectal bleeding was referred to our department for gastrointestinal (GI) bleeding study. She was in early post-menstrual period and had stable vital signs. A GI bleeding study with Tc-99m SC revealed uterine blush in the pelvis. The shape of activity and quick fading excluded a GI bleeding. To rule out an intermittent bleeding, patient underwent a second bleeding study with Tc-99m RBC. Serial images showed uterine "doughnut" in the pelvis. The activity neither changed in shape nor showed distal movement with time excluding a GI hemorrhage. Uterus in early proliferating phase could be a potential pitfall in GI bleeding studies.

Quinacrine nonsurgical female sterilization in Baroda, India: 23 years of follow-up of 84 women

OBJECTIVES

Evaluate the long-term effectiveness and safety of transcervical insertion of quinacrine hydrochloride pellets for nonsurgical female sterilization (QS).

METHODS

During the period June 1979 through January 1980, 84 women were admitted to a study at the Baroda Medical College and Hospital, Baroda, India. Our protocol called for three transcervical insertions of 252 mg of quinacrine hydrochloride to be deposited in the uterus of each patient. Follow-up was scheduled at 6, 12 and 48 months after the last administration.

RESULTS

These women were 25 to 39 years of age at the time of the QS procedure and now, 23 years later, have completed their reproductive years. There were 4 pregnancies subsequent to the completion of QS, all prior to their 4-year follow-up. Thus, the life-time failure rate for these women was 3.7%. Complaints were minor, especially when compared to surgical sterilization. There were no long-term effects suspected of being attributable to QS.

CONCLUSIONS

QS appears to be a reasonably effective method that is much safer than surgical sterilization.

A Nonincisional, Doppler-Guided Transvaginal Approach to Uterine Artery Identification and Control of Uterine Perfusion

STUDY OBJECTIVE

To determine the location and depth of uterine arteries from the vaginal fornix using a Doppler-guided nonincisional transvaginal approach.

DESIGN

Observational study (Canadian Task Force classification II-3).

SETTING

Two women's health and fertility centers.

PATIENTS

One hundred nine healthy premenopausal women (age >18 yrs).

INTERVENTION

Transvaginal uterine artery identification.

MEASUREMENTS AND MAIN RESULTS

After uterine size and position were determined, with a standard bivalve speculum in place, uterine arteries were located bilaterally using the DWL Multi-Dop B+ system with 8-MHz probe (Sipplingen, Germany) in toggle mode. Continuous Doppler mode was used to locate uterine arteries, and pulsed Doppler to estimate depth of the arteries from the vaginal fornix. The average uterine size was less than 8 weeks, with the largest measuring 18 weeks' gestational size. The right uterine artery could be identified between 8 and 11 o'clock positions, and was most commonly found at the 9 o'clock position (average depth 9.30 mm, range 4-17 mm). The left uterine artery could be identified between 1 and 4 o'clock positions and was most commonly found at the 3 o'clock position (average depth 8.88 mm, range 4-15 mm).

CONCLUSION

Due to ease of identification of uterine arteries transvaginally, despite differences in parity, uterine size, and position, access to and occlusion of uterine arteries with a Doppler-guided device might offer an alternative to invasive procedures intended to occlude uterine artery blood flow in women with symptomatic uterine leiomyomas.

Assessing congenital uterine anomalies: the role of three-dimensional ultrasonography

Congenital uterine anomalies are associated with a range of adverse reproductive outcomes but may also be found incidentally. Their significance in women with normal reproductive histories, who do not have a history of recurrent miscarriage or infertility, has been uncertain. The absence of these data has made it difficult to understand the true significance of congenital uterine anomalies found in women with adverse pregnancy outcomes. The advent of transvaginal three-dimensional ultrasonography has enabled the accurate, non-invasive, outpatient diagnosis of congenital uterine anomalies. It has enabled large-scale screening and morphological analysis of congenital uterine anomalies.

Uterine position at real embryo transfer compared with mock embryo transfer

BACKGROUND

The purpose of this study was to determine the consistency in the uterine position between mock and real embryo transfer.

METHODS

We reviewed 996 consecutive embryo transfer cycles (585 patients); 74% of patients had an anteverted (AV) uterus and 26% had a retroverted (RV) uterus at mock embryo transfer. All mock and real embryo transfers were performed under abdominal ultrasound guidance.

RESULTS

Of 623 fresh embryo transfers in patients with an AV uterus at mock embryo transfer, only 2% became RV, while 55% of 213 embryo transfers in patients with an RV uterus on mock embryo transfer converted to AV at real embryo transfer (P < 0.0001). For frozen-thawed embryo transfer, 12% of AV uteri at mock embryo transfer became RV, while 33% of RV uteri became AV (P = 0.01).

CONCLUSIONS

Our data suggest that an RV uterus at mock embryo transfer will often change position at real embryo transfer. Misdirecting the embryo transfer catheter can be avoided by accurate knowledge of the uterine position at the time of embryo transfer, which can be more accurately assessed by routine ultrasound guidance. Additionally, patients with an RV uterus at mock embryo transfer should still present with a full bladder for embryo transfer, since a significant number will convert to an AV position.

First trimester uterine, placental and yolk sac haemodynamics in pre-eclampsia and preterm labour

BACKGROUND

We hypothesized that impaired trophoblast invasion leads to umbilicoplacental blood flow disturbances that could be detected by Doppler ultrasonography during the first trimester of the pregnancy.

METHODS

After successful fresh IVF or ICSI programme, 41 of 47 enrolled subjects were followed up every 1-2 weeks between weeks 6 and 11 of gestation. Ten patients who later developed pre-eclampsia and/or preterm labour formed the study group and the control group consisted of 31 uncomplicated IVF/ICSI pregnancies. Doppler parameters of uterine, spiral, intraplacental, chorionic, umbilical and yolk sac haemodynamics were assessed.

RESULTS

At the week 8, the study group demonstrated higher (P < 0.05) maternal intraplacental resistance indices (RI) than the control group. A week later, yolk sac artery RI and umbilical artery mean velocity (V(mean)) in the study group were lower (P < 0.05) compared to the control group. In late first trimester, increased (P < 0.01) velocities and RI were observed in chorionic arteries of the study group. During early pregnancy, no difference in uterine and spiral artery haemodynamics and in umbilical artery pulsatility index (PI) values was observed between the groups.

CONCLUSIONS

Uterine and spiral artery RI and umbilical artery PI are unable to detect placental vascular disturbances during early pregnancy. Elevated intraplacental RI indicates increased maternal intraplacental impedance as early as week 8 of gestation. Decreased yolk sac artery RI and umbilical artery V(mean) in the study group at week 9 of gestation were speculated to indicate hampered transition of blood supply from yolk sac to umbilical circulation, underlining the emphasized role of yolk sac function for the maintenance of pregnancy.

Determination by echography of uterine changes around puberty in gilts and evaluation of a diagnosis of puberty

Three experiments were carried out to evaluate the use of ultrasonography in assessing the onset of puberty in gilts. In experiment 1, gilts (n = 17) were scanned 3 times per week beginning at 133 and continuing until 187 days of age. The ultrasonic appearance of the uterus was described, quantified and compared with the reproductive status observed at slaughter. The quantification of the pictures showed a different correlation in time for infantile, impubertal, prepubertal and pubertal stages. For pubertal females, "uterine area" increased at around 180 days of age, well-defined sections of the uterine horns appeared 3 +/- 0.5 days before puberty. In infantile and impubertal gilts during the same period of age, uterine images remained dark and homogeneous; no significant change in the "uterine area" was observed. This difference in images allowed an evaluation of the diagnosis of puberty. In experiment 2, the gilts (n = 123) were scanned, the result was verified at slaughter the day after by examination of the genital tract. The uterine weight of the gilts that had reached a prepubertal or pubertal stage was significantly greater (P = 0.0001) than that in impubertal gilts. The sensitivity and the specificity of the diagnosis were 91.9% and 96.5% respectively. Experiment 3 was performed on a farm and echographic examinations were carried out one and five days after gilts (n = 117) arrived at the piggery. Oestrus detection or blood sampling for progesterone determinations were used as tools to determine the reproductive status. The sensitivity and the specificity of the diagnosis were 98.9% and 100% respectively. This diagnosis of puberty is thus accurate.

Single uterine axial fast acquisition magnetic resonance fetal survey: is it feasible?

OBJECTIVES

To determine which non-biometric components of the ultrasound fetal survey can routinely be seen on a single fast acquisition magnetic resonance (MR) sequence aligned axial to the maternal uterus.

STUDY DESIGN

The non-biometric components of the routine fetal ultrasound examination were applied retrospectively to the initial MR single-shot fast spin-echo acquisition aligned axial to the maternal uterus in the normal fetus to determine whether these parameters could be routinely evaluated. Nineteen women with anatomically normal fetuses had a total of 31 MR studies performed for fetal or maternal indications, either as part of an indicated examination or as part of a study protocol approved by the institutional review board. The images in these 31 MR studies were reviewed by two independent examiners who were blinded to the other's assessment; concordance was necessary for a component to be adequately assessed. The Wilcoxon rank sum test was used to determine the effect of gestational age and fetal lie on the ability to assess non-biometric parameters.

RESULTS

Assessment was possible in 85% of the non-biometric parameters. Cord insertion, external genitalia and the four-chamber view of the heart were most problematic. In only two cases was the four-chamber view of the heart identified. Longitudinal lie allowed significantly more parameters (82%) to be evaluated than transverse lie (45%) (p < 0.003). No difference based on gestational age was found.

CONCLUSION

A single fast acquisition axial MR sequence can evaluate 85% of the non-biometric components of the fetal ultrasound survey. Fetal lie is an important confounder in the ability to resolve fetal anatomy with a single MR axial uterine acquisition.

Uterine volume in adolescents

The objective of the present study was to determine the uterine volume of adolescents by ultrasonography, and to correlate it with pregnancy during adolescence and with the immaturity of the female genital tract for pregnancy and delivery. A transverse observational study was conducted on 828 patients who were 10 to 40 years old by transabdominal ultrasonography and were divided into two groups: group 1 consisted of 477 (57.6%) adolescents and group 2 consisted of 351 (42.3%) women 20 to 40 years old. Uterine volume increased with the presence of menarche, age and parity (p < 0.05). Nulliparous and primiparous adolescents younger than 18 years old had a smaller uterine volume, 41.3 +/- 17.9 and 51.6 +/- 19.7 cm(3), respectively, than nulliparous and primiparous women 20 to 40 years old (p < 0.001). However, secundiparous adolescents had a uterine volume of 62.6 +/- 20.6 cm(3), which was significantly similar to the uterine volume of women 20 to 40 years old (p = 0.22). The differences in uterine volume between adolescents younger than 18 years old or with less than two deliveries and women who were 20 to 40 years old may be due to immaturity of the female genital tract for pregnancy and delivery among younger women, with a consequent higher incidence of preterm deliveries in this group.

Vascularisation de l’utérus en 3D et implantation

During the last decade transvaginal color Doppler has played an important role in increasing the understanding of early human development. Although our knowledge of early pregnancy development has recently improved, little is known about the most critical period of human development: implantation. Recent advances in three-dimensional ultrasound have made studies of follicular development, ovulation and uterine receptivity more accurate. Three-dimensional ultrasound facilitates determination of the antral follicle number, ovarian volume calculation and analysis of the intensity of ovarian stromal blood flow in a short time without increasing the patient's discomfort. It is also possible to determine predictors of IVF outcome by three-dimensional ultrasound. Favorable ovarian stromal vascularity is associated with higher number of retrieved oocytes and increased pregnancy rates. The high degree of endometrial perfusion shown by color Doppler ultrasonography and on three-dimensional power Doppler histograms on the day of embryo transfer can indicate a more favorable endometrial milieu for successful in vitro fertilization. Uterine septum is the most common uterine abnormality occurring in infertile women. Three-dimensional ultrasound can be used as a screening method for detection of uterine abnormalities in patients suffering from infertility.

Ultrasonographic evaluation of the pre-pubertal development of the reproductive tract in beef heifers

To study the development of the reproductive tract in heifers, the ovaries, uterus, cervix and vagina were examined by transrectal ultrasonography every 2 weeks, from 2 to 60 weeks after birth. First ovulation occurred at 63.7 +/- 1.1 weeks of age. Ovarian dimensions increased rapidly from 2 to 14 weeks of age, and increased again after 34 weeks of age (P<0.05). The size of the largest ovarian follicles increased from 8 to 14 weeks of age, from 38 to 42 weeks of age, and finally from 52 to 60 weeks of age (P<0.05). The number of follicles > or =3 mm in diameter tended to increase from 6 to 14 weeks of age (P<0.10) and increased significantly from 6 to 60 weeks of age (P<0.05). Mean numerical pixel values of the ovarian images decreased from 4 to 26 weeks of age, and then rose to 44 weeks of age (P<0.05). Diameter of the uterine body, cervix and vagina increased from 2 to 20-24 weeks of age, and again after 32 weeks of age (P<0.05). Mean numerical pixel values for the uterus and vagina decreased initially (uterus: 4-8 weeks and vagina: 6-22 weeks of age) and then increased (uterus: 14-42 weeks and vagina: 22-32 weeks of age; P<0.05). Pixel heterogeneity showed a consistent peak at 20-22 weeks of age for the uterus, cervix and vagina (P<0.05). In summary, in the heifer calf, the marked growth of the reproductive tract in the first few months of age, and prior to first ovulation, reflects phases of increased ovarian follicle (> or =3 mm in diameter) numbers and size. Ultrasonographic image analysis revealed patterns of numerical pixel values and heterogeneity that may be useful in determining important stages of growth and differentiation of the reproductive system.

Impact des techniques de transfert sur l’implantation

Embryo transfer is an important step in the success of IVF treatment. All efforts should be made to avoid difficult embryo transfers provoking bleeding or uterine contractions. Evaluation before IVF treatment, including a trial transfer and a uterine ultrasonography, should allow one to evaluate the transfer step, anticipate problems, and thus improve treatment. An hysteroscopy can be useful for uterine cavity exploration. It is also important to remove cervical mucus before introduce the transfer catheter. It is essential to deposit embryos as gently as possible during IVF, avoiding manoeuvres that might trigger uterine contractions which could adversely affect the results of this treatment. Soft catheters perform better, and ultrasound-guidance facilitates embryo transfer. Progesterone administration starting on the day of oocyte retrieval induces a decrease in uterine contraction frequency on the day of ET (embryo transfer). Both Wallace and CDD catheters perform similarly. Trial catheterization on the day of ET could prevent most of the unanticipated procedural difficulties during the transfer.