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Bayram A, De Munck N, Elkhatib I, Arnanz A, El-Damen A, Abdala A, Coughlan C, Garrido N, Vidales LM, Lawrenz B, Fatemi HM. The position of the euploid blastocyst in the uterine cavity influences implantation. Reprod Biomed Online 2021; 43:880-889. [PMID: 34474972 DOI: 10.1016/j.rbmo.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/03/2021] [Accepted: 02/14/2021] [Indexed: 01/10/2023]
Abstract
RESEARCH QUESTION Does the position of the euploid blastocyst in the uterine cavity upon transfer, measured as distance in millimetres (mm) from the fundus (DFF) to the air bubble, influence implantation potential? DESIGN A total of 507 single/double euploid frozen embryo transfer (FET) cycles at blastocyst stage were included retrospectively between March 2017 and November 2018 at a single centre. The patients were on average 33.3 years old. The FET were performed in natural cycles (n = 151) or hormone replacement therapy cycles (n = 356). RESULTS Of the 507 transfers, 370 (73.0%) resulted in a pregnancy, defined as human chorionic gonadotrophin concentration over 15 mIU/ml, and 341 (67.3%) in a clinical pregnancy, with an implantation rate of 62.0% and ongoing pregnancy rate of 59.6% (302/507). When comparing the number of embryos transferred, the pregnancy rate, clinical pregnancy rate and ongoing pregnancy rate were significantly higher after double-embryo transfer (DET) (P = 0.002: P < 0.001 and P = 0.002). The quality of the blastocyst in the single-embryo transfer group had a positive effect on the pregnancy rate (A versus B, P = 0.016; A versus C, P = 0.003) and clinical pregnancy rate (A versus C, P = 0.013). After performing a multivariate logistic regression analysis to consider the effect of all explanatory variables, a negative effect between DFF and pregnancy (P = 0.001), clinical pregnancy (P = 0.001) and ongoing pregnancy (P = 0.030) was found. When all variables remained constant, an increase of 1 mm of DFF changed the odds of pregnancy by 0.882, of clinical pregnancy by 0.891 and of ongoing pregnancy by 0.925. No significant effect of DFF was found on the miscarriage outcome (P = 0.089). CONCLUSIONS The depth of blastocyst replacement inside the uterine cavity may influence the pregnancy, clinical pregnancy and ongoing pregnancy rates and should be considered as an important factor to improve the success of IVF cycles.
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Affiliation(s)
- Aşina Bayram
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates.
| | | | | | - Ana Arnanz
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | | | - Andrea Abdala
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | | | - Nicolas Garrido
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | | | - Barbara Lawrenz
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates; Obstetrical Department, Women's University Hospital Tuebingen, Tuebingen, Germany
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2
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Davar R, Poormoosavi SM, Mohseni F, Janati S. Effect of embryo transfer depth on IVF/ICSI outcomes: A randomized clinical trial. Int J Reprod Biomed 2020; 18:723-732. [PMID: 33062918 PMCID: PMC7521168 DOI: 10.18502/ijrm.v13i9.7667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/04/2020] [Accepted: 03/01/2020] [Indexed: 11/26/2022] Open
Abstract
Background Although there has been remarkable advancement in the field of assisted reproductive technology, implantation failure remains a significant issue in most infertile couples receiving these treatments. Embryo transfer is important in assisted reproductive technology and directly affects the implantation rates and pregnancy outcomes. Objective To assess the effect of two different distance embryo transfer sites from fundal endometrial surface on the outcomes of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles. Materials and Methods A total of 180 women who were candidate for IVF/ ICSI/ embryo transfer in Yazd Research and Clinical Center for Infertility were equally assigned to two groups based on the distance between the fundal endometrial surface and catheter tip to investigate implantation, chemical and clinical pregnancy (group A: 15 ± 5 mm and group B: 25 ± 5 mm, respectively). Results The subjects in the group B showed significantly higher implantation rate, chemical and clinical pregnancy rate compared to the group A (p = 0.03, 0.01, 0.04, respectively). The rate of ongoing pregnancy and miscarriage indicated no significant differences between groups (p = 0.21, 0.27, respectively). Conclusion In conclusion, our study showed that the depth of embryo replacement inside the uterine cavity at a distance of 25 ± 5 mm beneath fundal endometrial surface have better effects on the pregnancy outcomes of IVF/ICSI cycles and can be considered as an important factor to improve the success of IVF cycles.
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Affiliation(s)
- Robab Davar
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Fereshteh Mohseni
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Sima Janati
- Department of Obstetrics and Gynecology, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran
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3
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Santos MMD, Silva AA, Barbosa ACP, Brum G, Nakagawa HM, Cabral I, Iglesias JR, Barbosa MWP. Embryo placement in IVF and reproductive outcomes: a cohort analysis and review. JBRA Assist Reprod 2019; 23:210-214. [PMID: 30875171 PMCID: PMC6724395 DOI: 10.5935/1518-0557.20190003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: The objective of the present study was to determine the influence of the
embryo placement depth on the endometrial cavity in relation to the
reproductive outcomes, after frozen-thawed embryo transfer performed under
transabdominal ultrasound guidance. Methods: Retrospective cohort study that evaluated the influence of the embryo
placement depth in the endometrial cavity in relation to the reproductive
outcomes of patients submitted to cryotransfer cycles at a private assisted
reproduction clinic, from 2012 to 2017. The patients were classified
according to three variables: <10mm, 10 to 15mm and >15mm. The primary
outcome was clinical pregnancy, and the secondary outcomes were miscarriage,
ongoing pregnancy and live birth. The data was summarized as relative risk,
with a 95%CI. Results: Clinical and ongoing pregnancy rates were higher in the 10-15mm and >15mm
Groups, when compared to the <10mm Group; there was no statistical
difference between the groups in terms of miscarriage and live birth rates.
We performed a subsequent analysis, using the same sample of patients,
comparing only the <10mm and ≥10mm variables. The ≥10mm
Group had better reproductive outcomes, with higher clinical and ongoing
pregnancy rates. Conclusion: Pregnancy rates are influenced by embryo transfer site, and better results
can be achieved when the tip of the catheter is placed in the central area
of the endometrial cavity, especially when the distance from the endometrial
fundus is >10mm.
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Affiliation(s)
| | | | | | - Guilherme Brum
- GENESIS - Center for Assistance in Human Reproduction, Brasília, DF, Brazil
| | | | - Iris Cabral
- GENESIS - Center for Assistance in Human Reproduction, Brasília, DF, Brazil
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4
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Saravelos SH, Li TC. Embryo transfer techniques. Best Pract Res Clin Obstet Gynaecol 2019; 59:77-88. [PMID: 30711373 DOI: 10.1016/j.bpobgyn.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Embryo transfer is the final and rate-limiting step of the assisted reproductive technique. Few advances have occurred in the last few decades with regard to this procedure. Studies conducted thus far have focused on factors and interventions taking place before, during and after this procedure. These factors are highly varied and range from methods to improve the psychological state of the patients to methods aimed at reducing uterine contractility and methods aimed at optimising the precise transfer of the embryo. The key question is which factors and interventions have thus far been proven to increase pregnancy rates and live birth rates. This paper aims to review the evidence relating to embryo transfer techniques in a systematic manner with a view to provide practical recommendations to practitioners involved in the procedure.
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Affiliation(s)
| | - Tin-Chiu Li
- Assisted Reproductive Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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5
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Yayla Abide C, Ozkaya E, Sanverdi I, Bostancı Ergen E, Kurek Eken M, Devranoglu B, Bilgiç BE, Kilicci C, Kayatas Eser S. Prospective Randomized Trial Comparing Embryo Transfers of Cases with and without Catheter Rotation during Its Withdrawal. Gynecol Obstet Invest 2018; 83:397-403. [PMID: 29758560 DOI: 10.1159/000489493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/21/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare embryo transfer (ET) technique based on catheter rotation during its withdrawal in cases with unexplained infertility in a prospective, randomized trial (NCT03097042). METHODS Two hundred intracytoplasmic sperm injection (ICSI) patients undergoing ET with cleaving or blastocyst-stage fresh embryos were randomized into 2 groups: cases with (n = 100), and without (n = 100) catheter rotation during its withdrawal. Groups were matched for age and some clinical parameters. A soft catheter was used to transfer a single embryo with catheter rotation during its withdrawal in the study group and without rotation in the control. The use of a stiff catheter or tenaculum was not needed in any case. Groups were compared in terms of cycle characteristics and clinical pregnancy rates. RESULTS Pregnancy rate was significantly higher in the study group (41 vs. 26%, p = 0.04). Clinical pregnancy rate was also significantly higher in the study group (39 vs. 25%, OR 1.9 [1.1-3.5], p = 0.05). On the other hand, the ongoing pregnancy rate was similar between the 2 groups (33 vs. 23%, p = 0.2). CONCLUSION Catheter rotation during its withdrawal may be associated with increased pregnancy and clinical pregnancy rates; however, the difference in ongoing pregnancy rates did not reach statistical significance.
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6
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Singh N, Lata K, Malhotra N, Vanamail P. Correlation of Site of Embryo Transfer with IVF Outcome: Analysis of 743 Cycles from a Single Center. J Hum Reprod Sci 2017; 10:102-107. [PMID: 28904498 PMCID: PMC5586082 DOI: 10.4103/jhrs.jhrs_54_15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the influence of site of embryo transfer (ET) on reproductive outcome. MATERIALS AND METHODS A retrospective analysis of 743 ultrasound-guided ET in fresh in vitro fertilization (IVF) cycles from a single center over a period of 4 years was conducted. The distance between the fundal endometrial surface and the air bubble was measured, and accordingly, patients were divided into four groups (≤10 mm; >10 and ≤15 mm; >15 and 20 mm; >20 and <25 mm). SETTING Tertiary Assisted Reproductive Technology (ART) center. PATIENTS All patients enrolled in the IVF program undergoing ET. INTERVENTIONS Controlled ovarian hyperstimulation (OS), IVF, and ET. MAIN OUTCOME MEASURES Cleavage rate and clinical pregnancy rate. RESULTS Clinical pregnancy rate was significantly more in groups 2 and 3 compared to the other groups. Logistic regression analysis showed that one unit increase in embryos transfer will enhance the pregnancy outcome about 3.7 (adjusted odds ratio) times with 95% confidence limits 2.6 to 5.4. Similarly, pregnancy outcome will be 3.1 (95% confidence limits: 1.5-6.4) times higher for distance group >15 and <20 mm compared to less than 10-mm distance group. Ectopic pregnancy rates were similar in all the four groups. CONCLUSION The present study demonstrates that site of ET has significant difference on reproductive outcome.
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Affiliation(s)
- Neeta Singh
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Kusum Lata
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Neena Malhotra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - P Vanamail
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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7
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Kava-Braverman A, Martínez F, Rodríguez I, Álvarez M, Barri PN, Coroleu B. What is a difficult transfer? Analysis of 7,714 embryo transfers: the impact of maneuvers during embryo transfers on pregnancy rate and a proposal of objective assessment. Fertil Steril 2017; 107:657-663.e1. [DOI: 10.1016/j.fertnstert.2016.11.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/28/2016] [Accepted: 11/21/2016] [Indexed: 12/01/2022]
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Plowden TC, Hill MJ, Miles SM, Hoyt B, Yauger B, Segars JH, Csokmay JM, Chason RJ. Does the Presence of Blood in the Catheter or the Degree of Difficulty of Embryo Transfer Affect Live Birth? Reprod Sci 2016; 24:726-730. [PMID: 27655772 DOI: 10.1177/1933719116667607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The technique used for embryo transfer (ET) can affect implantation. Prior research that evaluated the effect of postprocedural blood of the transfer catheter tip have yielded mixed results, and it is unclear whether this is actually a marker of difficulty of the transfer. Our objective was to estimate the effect of blood at the time of ET and the difficulty of ET on live birth rates (LBR). This retrospective cohort study utilized generalized estimating equations (GEEs) with nesting for repeated cycles for all analyses. Univariate modeling was performed and a final multivariate (adjusted) GEE model accounted for all significant confounders. Embryo transfers were subjectively graded (easy, medium, or hard) by a physician at the time of transfer. The presence of blood at ET was associated with more difficult ETs, retained embryos, and presence of mucous in the catheter. In the univariate analysis, ET with blood was not associated with live birth, while the degree of difficulty for ET had a negative impact on LBR. In the final multivariate GEE model, which accounts for repeated cycles from a patient, the only factors associated with an increased LBR were the degree of difficulty of the ET, female age, and blastocyst transfer. After controlling for confounding variables, the presence of blood in the transfer catheter was not associated with the likelihood of pregnancy and thus was not an independent predictor of cycle outcome. This indicates that the difficulty of the transfer itself was a strong negative predictor of pregnancy.
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Affiliation(s)
- Torie C Plowden
- 1 Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver NICHD, National Institutes of Health, Bethesda, MD, USA
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Micah J Hill
- 1 Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver NICHD, National Institutes of Health, Bethesda, MD, USA
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Shana M Miles
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Belinda Yauger
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - James H Segars
- 4 Johns Hopkins Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - John M Csokmay
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rebecca J Chason
- 2 Walter Reed National Military Medical Center, Bethesda, MD, USA
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9
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Revelli A, Rovei V, Dalmasso P, Gennarelli G, Racca C, Evangelista F, Benedetto C. Large randomized trial comparing transabdominal ultrasound-guided embryo transfer with a technique based on uterine length measurement before embryo transfer. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:289-95. [PMID: 26924732 DOI: 10.1002/uog.15899] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 02/19/2016] [Accepted: 02/22/2016] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To compare in a randomized, non-inferiority trial the embryo transfer (ET) technique based on uterine length measurement before transfer (ULMbET) with transabdominal ultrasound-guided embryo transfer (TA-UGET) in a large population of patients undergoing in-vitro fertilization (IVF). METHODS Patients undergoing IVF with ET with cleaving fresh embryos were randomized to receive ULMbET or TA-UGET. The transfer of one to three embryos on day 2-3 of culture was performed using a soft catheter either under transabdominal ultrasound guidance (TA-UGET group) or after measurement of the uterine cavity by transvaginal ultrasound and calculation of the discharge site (ULMbET group). The primary outcome measures were clinical pregnancy rate, ongoing pregnancy rate and implantation rate, and secondary outcomes included patient discomfort during ET. RESULTS A total of 1648 patients undergoing IVF were randomized to receive ULMbET (n = 828) or TA-UGET (n = 820) and were included in the analysis. Comparable clinical pregnancy rate (38.2% vs 38.9%), implantation rate (24.8% vs 25.2%) and ongoing pregnancy rate (33.1% vs 34.8%) were observed in ULMbET and TA-UGET groups. The discomfort intensity score and the proportion of patients with moderate-to-severe discomfort during ET were significantly higher in the TA-UGET group (2.6 vs 1.5 visual analog scale points and 19.8% vs 1.2%; P = 0.045 and P = 0.003, respectively). CONCLUSION The ULMbET technique leads to IVF results comparable to those obtained with UGET, but is better tolerated than is TA-UGET and is technically easier to perform for a single operator. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Revelli
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy.
| | - V Rovei
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - P Dalmasso
- Medical Statistics Unit, Department of Public Health and Microbiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - G Gennarelli
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - C Racca
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - F Evangelista
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - C Benedetto
- Gynecology and Obstetrics 1U, Physiopathology of Reproduction and IVF Unit, Sant'Anna Hospital, University of Turin, Turin, Italy
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Saravelos SH, Wong AWY, Chan CPS, Kong GWS, Li TC. How often does the embryo implant at the location to which it was transferred? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:106-112. [PMID: 26437908 DOI: 10.1002/uog.15778] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine how often the embryo implants exactly at the site of transfer and what additional factors may affect the eventual site of implantation in assisted reproductive technology (ART) cycles. METHODS This was a prospective observational study of women undergoing ART treatment in a tertiary university unit. Several factors inherent to the embryo transfer (ET), such as the location of the air bubbles and uterine contractility at 1 and at 60 min after ET were assessed with two-dimensional and three-dimensional (3D) ultrasound. In women in whom there was a resulting pregnancy, the position of the gestational sac (i.e. right, left, center or low) was subsequently assessed using 3D ultrasound, and predictors of its location were evaluated. RESULTS Of 239 recruited women with visualization of air bubbles at ET, 71 singleton gestational sacs were subsequently observed on 3D ultrasound. Overall, 40.8% (29/71) of embryos implanted at the location where the air bubbles were visualized at 1 min after ET, and 50.7% (36/71) implanted where the air bubbles were visualized at 60 min after ET (Cohen's kappa coefficients 0.21 and 0.37, respectively; comparison of agreement values: P = 0.28). Specifically, at 1 min the correspondence between the location of the air bubble and embryo implantation was 37.5% (6/16), 57.1% (8/14), 36.8% (7/19) and 36.4% (8/22) for right, left, central and lower uterus, respectively (4 × 4 contingency table, P < 0.01); at 60 min, the correspondence was 72.2% (13/18), 50.0% (9/18), 33.3% (8/24) and 85.7% (6/7), respectively (5 × 4 contingency table, P < 0.001). In addition, higher vs lower frequency of uterine contractions at 60 min was associated with different sites of implantation (5.6% (1/18), 11.1% (2/18), 27.8% (5/18) and 55.6% (10/18) vs 34.0% (18/53), 24.5% (13/53), 13.2% (7/53) and 28.3% (15/53) for right, left, central and lower uterus, respectively, P < 0.05). In particular, a high uterine contraction frequency following ET was associated with a twofold increased chance of the pregnancy implanting in the lower part of the uterine cavity (relative risk, 1.96 (95% CI, 1.08-3.56), P < 0.05). CONCLUSIONS The position of the air bubbles within the first 60 min of ET appears to predict the site of implantation in approximately half of cases, denoting an overall poor agreement. This implies significant embryo migration, and has important clinical implications, as it demonstrates that other factors such as uterine contractility may dictate where the embryo will eventually implant following transfer. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S H Saravelos
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - A W Y Wong
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - C P S Chan
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - G W S Kong
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - T-C Li
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Caanen MR, van der Houwen LE, Schats R, Vergouw CG, de Leeuw B, Lambers MJ, Groeneveld E, Lambalk CB, Hompes PG. Embryo Transfer with Controlled Injection Speed to Increase Pregnancy Rates: A Randomized Controlled Trial. Gynecol Obstet Invest 2016; 81:394-404. [DOI: 10.1159/000443954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 01/11/2016] [Indexed: 11/19/2022]
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12
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Saravelos SH, Wong AWY, Chan CPS, Kong GWS, Cheung LP, Chung CHS, Chung JPW, Li TC. Assessment of the embryo flash position and migration with 3D ultrasound within 60 min of embryo transfer. Hum Reprod 2016; 31:591-6. [DOI: 10.1093/humrep/dev343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 12/14/2015] [Indexed: 11/13/2022] Open
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13
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Gingold JA, Lee JA, Rodriguez-Purata J, Whitehouse MC, Sandler B, Grunfeld L, Mukherjee T, Copperman AB. Endometrial pattern, but not endometrial thickness, affects implantation rates in euploid embryo transfers. Fertil Steril 2015; 104:620-8.e5. [PMID: 26079695 PMCID: PMC4561002 DOI: 10.1016/j.fertnstert.2015.05.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/29/2015] [Accepted: 05/29/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the relationship of endometrial thickness (EnT) and endometrial pattern (EnP) to euploid embryo transfer (ET) outcomes. DESIGN Retrospective cohort. SETTING Private academic clinic. PATIENT(S) Patients (n = 277; age 36.1 ± 4.0 years) whose embryos (n = 476) underwent aneuploidy screening with fresh (n = 176) or frozen (n = 180) ET from July 2010 to March 2014. INTERVENTION(S) The EnT and EnP were measured on trigger day and at ET. Patients were stratified by age and cycle type (fresh or frozen). Cycle data were combined at trigger day, but separated at ET day. MAIN OUTCOME MEASURE(S) Outcome measures were implantation rate, pregnancy rate, and clinical pregnancy rate. Analysis was conducted using χ(2) analysis and Fisher's exact test. RESULT(S) A total of 234 gestational sacs, 251 pregnancies, and 202 clinical pregnancies resulted from 356 cycles. The EnT (9.6 ± 1.8 mm; range: 5-15 mm) at trigger day (n = 241 cycles), as a continuous or categorical variable (≤8 vs. >8 mm), was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate. The EnT at day of fresh ET (9.7 ± 2.2 mm; range: 4.4-17.9 mm) (n = 176 cycles) or frozen ET (9.1 ± 2.1 mm; range: 4.2-17.7 mm) (n = 180 cycles) was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate. Type 3 EnP at trigger day was associated with increased serum progesterone at trigger and a decreased implantation rate, compared with type 2 EnP. The EnP at fresh or frozen ET was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate. CONCLUSION(S) Within the study population, EnT was not significantly associated with clinical outcomes of euploid ETs. A type 3 EnP at trigger day suggests a prematurely closed window of implantation.
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Affiliation(s)
- Julian A Gingold
- Reproductive Medicine Associates of New York, New York, New York; Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Joseph A Lee
- Reproductive Medicine Associates of New York, New York, New York
| | | | | | - Benjamin Sandler
- Reproductive Medicine Associates of New York, New York, New York; Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lawrence Grunfeld
- Reproductive Medicine Associates of New York, New York, New York; Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tanmoy Mukherjee
- Reproductive Medicine Associates of New York, New York, New York; Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan B Copperman
- Reproductive Medicine Associates of New York, New York, New York; Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
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14
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Abstract
BACKGROUND Meta-analysis revealed that embryo placement 20 mm from the fundal endometrial surface resulted in higher pregnancy rate, ongoing pregnancy rate, and live birth rate compared with placement 10 mm from the fundal endometrial surface. Pregnancy and implantation rates according to relative position were higher when the catheter tip was positioned close to the middle of the endometrial cavity. The aim of the current study is to evaluate differences in implantation and pregnancy rates if the site of embryo transfer is 2 cm distance from the fundal endometrium (DFE) compared to the midpoint of the endometrial cavity length (ECL). METHODS Patients were randomized to one of two groups: in group A (n = 98, 98 IVF-ET cycles), the embryo transfer catheter tip was positioned 2 cm DFE, while that in group B (n = 97, 97 IVF-ET cycles) was positioned at the midpoint of the ECL. We compared pregnancy outcomes of implantation rate, chemical pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, ectopic pregnancy rate, and miscarriage rate in the two groups. RESULTS Analysis of implantation rate (19.5 ± 27.7 vs. 21.7 ± 32.6; p = 0.6), chemical pregnancy rate (51 % vs. 50.5 %; p = 0.94), clinical pregnancy rate (35.7 % vs. 38.1 %; p = 0.73), ongoing pregnancy rate (31.6 % vs. 30.9 %; p = 0.92), ectopic pregnancy rate (8.6 % vs. 2.7 %; p = 0.35), and miscarriage rate (11.4 % vs. 16.2 %; 0.74) revealed comparable results for both groups. CONCLUSIONS Implantation and pregnancy rates were not influenced by the site of the ET catheter tip being 2 cm DFE compared to at the midpoint of the ECL. ISRCTN ISRCTN15972342.
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Affiliation(s)
- Hwang Kwon
- Department of Obstetrics and Gynecology, CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
- College of Medicine, CHA University and CHA Fertility Center of Bundang CHA General Hospital, 351 Yatap-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-712, Korea.
| | - Dong-Hee Choi
- Department of Obstetrics and Gynecology, CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
| | - Eun-Kyung Kim
- CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
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15
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Rovei V, Dalmasso P, Gennarelli G, Lantieri T, Basso G, Benedetto C, Revelli A. IVF outcome is optimized when embryos are replaced between 5 and 15 mm from the fundal endometrial surface: a prospective analysis on 1184 IVF cycles. Reprod Biol Endocrinol 2013; 11:114. [PMID: 24341917 PMCID: PMC3867220 DOI: 10.1186/1477-7827-11-114] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 12/02/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Some data suggest that the results of human in vitro fertilization (IVF) may be affected by the site of the uterine cavity where embryos are released. It is not yet clear if there is an optimal range of embryo-fundus distance (EFD) within which embryos should be transferred to optimize IVF outcome. METHODS The present study included 1184 patients undergoing a blind, clinical-touch ET of 1-2 fresh embryos loaded in a soft catheter with a low amount of culture medium. We measured the EFD using transvaginal US performed immediately after ET, with the aim to assess (a) if EFD affects pregnancy and implantation rates, and (b) if an optimal EFD range can be identified. RESULTS Despite comparable patients' clinical characteristics, embryo morphological quality, and endometrial thickness, an EFD between 5 and 15 mm allowed to obtain significantly higher pregnancy and implantation rates than an EFD above 15 mm. The abortion rate was much higher (although not significantly) when EFD was below 5 mm than when it was between 5 and 15 mm. Combined together, these results produced an overall higher ongoing pregnancy rate in the group of patients whose embryos were released between 5 and 15 mm from the fundal endometrial surface. CONCLUSIONS The site at which embryos are released affects IVF outcome and an optimal EFD range exists; this observations suggest that US-guided ET could be advantageous vs. clinical-touch ET, as it allows to be more accurate in releasing embryos within the optimal EFD range.
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Affiliation(s)
- Valentina Rovei
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
| | - Paola Dalmasso
- Medical Statistics Unit, Department of Public Health and Paediatrics, University of Torino, Torino, Italy
| | - Gianluca Gennarelli
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
| | - Teresa Lantieri
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
| | - Gemma Basso
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
| | - Chiara Benedetto
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
| | - Alberto Revelli
- Physiopatology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, Sant’Anna Hospital, Torino, Italy
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Szmyga MJ, Rybak EA, Nejat EJ, Banks EH, Whitney KD, Polotsky AJ, Heller DS, Meier UT. Quantification of nucleolar channel systems: uniform presence throughout the upper endometrial cavity. Fertil Steril 2013; 99:558-64. [PMID: 23137760 PMCID: PMC4074880 DOI: 10.1016/j.fertnstert.2012.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 10/03/2012] [Accepted: 10/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the prevalence of nucleolar channel systems (NCSs) by uterine region, applying continuous quantification. DESIGN Prospective clinical study. SETTING Tertiary care academic medical center. PATIENT(S) Forty-two naturally cycling women who underwent hysterectomy for benign indications. INTERVENTION(S) NCS presence was quantified by a novel method in six uterine regions-fundus, left cornu, right cornu, anterior body, posterior body, and lower uterine segment (LUS)-with the use of indirect immunofluorescence. MAIN OUTCOME MEASURE(S) Percentage of endometrial epithelial cells (EECs) with NCSs per uterine region. RESULT(S) NCS quantification was observer independent (intraclass correlation coefficient 0.96) and its intrasample variability low (coefficient of variation 0.06). Eleven of 42 hysterectomy specimens were midluteal, ten of which were analyzable with nine containing >5% EECs with NCSs in at least one region. The percentage of EECs with NCSs varied significantly between the LUS (6.1%; interquartile range [IQR] 3.0-9.9) and the upper five regions (16.9%; IQR 12.7-23.4), with fewer NCSs in the basal layer of the endometrium (17 ± 6%) versus the middle (46 ± 9%) and luminal layers (38 ± 9%) of all six regions. CONCLUSION(S) NCS quantification during the midluteal phase demonstrates uniform presence throughout the endometrial cavity, excluding the LUS, with a preference for the functional luminal layers. Our quantitative NCS evaluation provides a benchmark for future studies and further supports NCS presence as a potential marker for the window of implantation.
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Affiliation(s)
- Michael J. Szmyga
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY
| | - Eli A. Rybak
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY
- Department of Obstetrics & Gynecology and Women's Health, and Albert Einstein College of Medicine, Bronx, NY
| | - Edward J. Nejat
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY
- Department of Obstetrics & Gynecology and Women's Health, and Albert Einstein College of Medicine, Bronx, NY
| | - Erika H. Banks
- Department of Obstetrics & Gynecology and Women's Health, and Albert Einstein College of Medicine, Bronx, NY
| | | | - Alex J. Polotsky
- Department of Obstetrics & Gynecology and Women's Health, and Albert Einstein College of Medicine, Bronx, NY
| | - Debra S. Heller
- Department of Pathology, UMDNJ – New Jersey Medical School, Newark, NJ
| | - U. Thomas Meier
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY
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17
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Tiras B, Korucuoglu U, Polat M, Saltik A, Zeyneloglu HB, Yarali H. Effect of air bubble localization after transfer on embryo transfer outcomes. Eur J Obstet Gynecol Reprod Biol 2012; 164:52-4. [PMID: 22682963 DOI: 10.1016/j.ejogrb.2012.05.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 04/21/2012] [Accepted: 05/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Our study aimed to provide information about the effects of air bubble localization after transfer on embryo transfer outcomes. STUDY DESIGN Retrospective analysis of 7489 ultrasound-guided embryo transfers. Group 1 included 6631 embryo transfers in which no movement of the air bubbles was observed after transfer. Group 2 consisted of 407 embryo transfers in which the air bubbles moved towards the uterine fundus spontaneously, a little time after transfer. Group 3 included 370 embryo transfers in which the air bubbles moved towards the uterine fundus with ejection, immediately after transfer. Group 4 consisted of 81 embryo transfers in which the air bubbles moved towards the cervical canal. RESULTS The four patient groups were different from one another with respect to positive pregnancy tests. Post hoc test revealed that this difference was between group 4 and other groups. CONCLUSIONS An initial finding of our study was significantly decreased positive pregnancy test rates and clinical pregnancy rates with air bubbles moving towards the cervical canal after transfer. Although air bubbles moving towards the uterine fundus with ejection were associated with higher pregnancy rates, higher miscarriage rates and similar live birth rates were observed compared to air bubbles remaining stable after transfer.
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Affiliation(s)
- Bulent Tiras
- Gazi University Faculty of Medicine, Ankara, Turkey
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18
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Kovacs P, Sajgo A, Rarosi F, Kaali SG. Does it really matter how far from the fundus embryos are transferred? Eur J Obstet Gynecol Reprod Biol 2012; 162:62-6. [DOI: 10.1016/j.ejogrb.2012.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 01/18/2012] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
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19
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The effect of air bubble position after blastocyst transfer on pregnancy rates in IVF cycles. Fertil Steril 2011; 95:944-7. [DOI: 10.1016/j.fertnstert.2010.07.1063] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 07/06/2010] [Accepted: 07/11/2010] [Indexed: 11/22/2022]
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20
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Grygoruk C, Sieczynski P, Pietrewicz P, Mrugacz M, Gagan J, Mrugacz G. Pressure changes during embryo transfer. Fertil Steril 2011; 95:538-41. [DOI: 10.1016/j.fertnstert.2010.04.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 04/27/2010] [Accepted: 04/27/2010] [Indexed: 10/19/2022]
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21
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Welmerink DB, Voigt LF, Daling JR, Mueller BA. Infertility treatment use in relation to selected adverse birth outcomes. Fertil Steril 2010; 94:2580-6. [DOI: 10.1016/j.fertnstert.2010.03.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 02/26/2010] [Accepted: 03/01/2010] [Indexed: 11/29/2022]
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22
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Mains L, Van Voorhis BJ. Optimizing the technique of embryo transfer. Fertil Steril 2010; 94:785-90. [DOI: 10.1016/j.fertnstert.2010.03.030] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 03/09/2010] [Indexed: 11/17/2022]
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23
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Muñoz M, Meseguer M, Lizán C, Ayllón Y, Pérez-Cano I, Garrido N. Bleeding during transfer is the only parameter of patient anatomy and embryo quality that affects reproductive outcome: a prospective study. Fertil Steril 2009; 92:953-955. [DOI: 10.1016/j.fertnstert.2009.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 02/03/2009] [Accepted: 02/04/2009] [Indexed: 11/29/2022]
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24
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Evaluation of the embryo transfer protocol by a laboratory model of the uterus. Fertil Steril 2007; 88:485-93. [DOI: 10.1016/j.fertnstert.2006.11.127] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 11/27/2006] [Accepted: 11/27/2006] [Indexed: 11/22/2022]
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25
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Lambers MJ, Dogan E, Lens JW, Schats R, Hompes PGA. The position of transferred air bubbles after embryo transfer is related to pregnancy rate. Fertil Steril 2007; 88:68-73. [PMID: 17433316 DOI: 10.1016/j.fertnstert.2006.11.085] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 11/16/2006] [Accepted: 11/16/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The possibility to visualize the transfer air bubbles is one of the main benefits of ultrasonographic-guided embryo transfer. The objective of this study was to analyze the relation between the position of the air bubbles and pregnancy rates. DESIGN Prospective data-analysis. SETTING University fertility clinic. PATIENT(S) IVF and intracytoplasmic sperm injection patients. INTERVENTION(S) Transabdominal ultrasonographic guidance at embryo transfer. MAIN OUTCOME MEASURE(S) Pregnancy rate, length endometrial plate, distance catheter to fundus, distance air bubbles to fundus. RESULT(S) Analysis of 367 consecutive ultrasonographic-guided embryo transfers following IVF or intracytoplasmic sperm injection treatment. Both absolute and relative position of the air bubbles were significantly closer to the fundus in patients who became pregnant compared with patients who did not become pregnant. When the relative position of the air bubbles was in the fundal half of the endometrial plate pregnancy rates were significantly higher compared with the lower half of the endometrial plate, 43.0% and 24.4%, respectively, P=.002. Multiple regression analysis revealed the relative position as an independently associated determinant for pregnancy. CONCLUSION(S) The position of the air bubbles after embryo transfer is related to pregnancy rate; the highest pregnancy rates are found when the air bubbles end up closer to the fundus.
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Affiliation(s)
- Marieke J Lambers
- Department of Obstetrics, Gynaecology and Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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26
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Confino E, Zhang J, Risquez F. Air bubble migration is a random event post embryo transfer. J Assist Reprod Genet 2007; 24:223-6. [PMID: 17431757 PMCID: PMC3454967 DOI: 10.1007/s10815-007-9120-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 02/20/2007] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Air bubble location following embryo transfer (ET) is the presumable placement spot of embryos. The purpose of this study was to document endometrial air bubble position and migration following embryo transfer. DESIGN Multicenter prospective case study. MATERIALS AND METHODS Eighty-eight embryo transfers were performed under abdominal ultrasound guidance in two countries by two authors. A single or double air bubble was loaded with the embryos using a soft, coaxial, end opened catheters. The embryos were slowly injected 10-20 mm from the fundus. Air bubble position was recorded immediately, 30 minutes later and when the patient stood up. RESULTS Bubble marker location analysis revealed a random distribution without visible gravity effect when the patients stood up. The bubble markers demonstrated splitting, moving in all directions and dispersion. CONCLUSION Air bubbles move and split frequently post ET with the patient in the horizontal position, suggestive of active uterine contractions. Bubble migration analysis supports a rather random movement of the bubbles and possibly the embryos. Standing up changed somewhat bubble configuration and distribution in the uterine cavity. Gravity related bubble motion was uncommon, suggesting that horizontal rest post ET may not be necessary. This report challenges the common belief that a very accurate ultrasound guided embryo placement is mandatory. The very random bubble movement observed in this two-center study suggests that a large "window" of embryo placement maybe present.
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Affiliation(s)
- E Confino
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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27
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Frankfurter D, Dayal M, Dubey A, Peak D, Gindoff P. Novel follicular-phase gonadotropin-releasing hormone antagonist stimulation protocol for in vitro fertilization in the poor responder. Fertil Steril 2007; 88:1442-5. [PMID: 17481626 DOI: 10.1016/j.fertnstert.2007.01.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2006] [Revised: 01/02/2007] [Accepted: 01/02/2007] [Indexed: 11/15/2022]
Abstract
Poor responders continue to be vexing in infertility therapy. By using GnRH antagonists before ovarian stimulation, we demonstrate an improvement in oocyte, embryo, and zygote yield in patients with a prior poor response.
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Affiliation(s)
- David Frankfurter
- The George Washington University School of Medicine, Division of Reproductive Endocrinology, Fertility and IVF, Washington, DC 20037, USA.
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28
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Abstract
Embryo transfer (ET) is the final manual intervention in extracorporeal fertilization in which an embryo is transferred into the uterus by a transcervical catheter. The low rates of embryo implantation within the uterus are attributed, among other factors, to the ET technique, which depends on a multitude of anatomical, physiological, and mechanical aspects. We developed computational and experimental models to simulate ET to examine the contribution of mechanical features to the success of this procedure. The experimental model allowed laboratory simulations of the dispersion of the catheter load as a result of different injection speeds into a tilted uterine model. The mathematical model analyzed potential trajectories of the transferred embryos resulting from the interaction between the injection velocity and the intrauterine flows caused by uterine peristalsis. The simulations revealed the important contribution of mechanical parameters, such as the position of the uterus and the presence of air in the catheter load. The latter was found to increase the potential for the embryo to be near the fundal area during the time limit for implantation. Based on the results of our simulations, we recommended performing ET in a patient-specific position in which the fundus will be the highest point above the horizon and that the load be delivered slowly, that is, not less than 10 s. We also recommended placing the tip of the catheter at the mid cavity to avoid ectopic pregnancy.
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Affiliation(s)
- Osnat Eytan
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Medical Center, Tel Aviv 64239, Israel.
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29
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Kosmas IP, Janssens R, De Munck L, Al Turki H, Van der Elst J, Tournaye H, Devroey P. Ultrasound-guided embryo transfer does not offer any benefit in clinical outcome: a randomized controlled trial. Hum Reprod 2007; 22:1327-34. [PMID: 17289683 DOI: 10.1093/humrep/dem001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ultrasound-guided embryo transfer (ET) is widely suggested as a standard clinical practice that improves overall embryo implantation and pregnancy rates. Various studies of this issue suffer from methodological pitfalls, so that a randomized controlled trial, which overcomes these problems, might be valuable. METHODS Three hundred women aged <40, who underwent fresh ET, were included in this randomized, double-blind controlled trial. The K-J-SPPE echo tip soft catheter was used for the ultrasound-guided ET and the traditional K-Soft catheter for ETs not using ultrasound. One experienced operator performed all ETs. The primary study outcome was overall pregnancy rate (defined as the number of positive hCG results per transfer). RESULTS No significant differences between groups were found regarding baseline patient and embryological characteristics, except for male factor and unexplained infertility (higher in the blind and ultrasound-guided ET group, respectively, P < 0.05). Overall pregnancy rates were 53.3 and 51.3% in the ultrasound-guided and blind ET group, respectively. Two ectopic pregnancies were reported in each group. Difficulty in cervical negotiation did not differ between the two groups. CONCLUSIONS In patients undergoing ET by an experienced operator, ultrasound guidance did not provide any benefit in terms of overall clinical pregnancy and embryo implantation rates.
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Affiliation(s)
- I P Kosmas
- Centre for Reproductive Medicine, Dutch-Speaking Brussels Free University, Brussels, Belgium.
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30
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Frishman GN, Allsworth JE, Gannon JB, Wright KP. Use of phenazopyridine for reducing discomfort during embryo transfer. Fertil Steril 2007; 87:1010-4. [PMID: 17239870 DOI: 10.1016/j.fertnstert.2006.08.097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 08/12/2006] [Accepted: 08/12/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The embryo transfer is a critical part of in vitro fertilization. When performed under abdominal ultrasound guidance, the embryo transfer procedure requires a full bladder. Patients often state that the discomfort of the distended bladder causes more pain than the actual transfer procedure. Phenazopyridine HCl is a bladder analgesic. The objective of this study was to determine if a single dose of phenazopyridine prior to embryo transfer reduces patient discomfort during that procedure. DESIGN Prospective randomized double-blinded clinical trial. SETTING University-based Reproductive Medicine practice. PATIENT(S) Eighty-five reproductive age infertile women undergoing in vitro fertilization. INTERVENTION(S) Phenazopyridine (200 mg) or placebo taken 1 hour prior to embryo transfer utilizing transabdominal sonography. MAIN OUTCOME MEASURE(S) Pain as assessed by visual analogue pain scale and physician and nurse assessment of patient discomfort. RESULT(S) Study groups were similar in their demographic background. Mean pain score as assessed by a visual analogue pain scale during the procedure was 2.95 +/- 2.4 in the placebo group, and 3.03 +/- 2.6 in the active medication group (NS). There were also no significant differences in the observations of pain assessments. CONCLUSION(S) Phenazopyridine used in a single dose prior to embryo transfer does not alleviate patient discomfort.
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Affiliation(s)
- Gary N Frishman
- Department of Obstetrics and Gynecology, Women & Infants' Hospital, Brown Medical School, Providence, Rhode Island 02905, USA.
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31
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Eytan O, Zaretsky U, Jaffa AJ, Elad D. In vitro simulations of embryo transfer in a laboratory model of the uterus. J Biomech 2007; 40:1073-80. [PMID: 16797022 DOI: 10.1016/j.jbiomech.2006.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Accepted: 04/24/2006] [Indexed: 11/16/2022]
Abstract
Embryo transfer (ET) is the final manual intervention during which the newly formed embryo is placed within the uterus by a transcervical catheter. The loading of the syringe-catheter complex with the transferred volume consists of the transfer media (which contains the embryos) separated by air spaces on both sides. The dynamics involved in injecting the syringe-catheter complex is not well understood nor has it been investigated to date. We developed an in vitro experimental setup for simulations of ET into a rigid transparent uterine model. The catheter was loaded in sequences of liquid and air as it is in the clinical setting. The transferred liquid was colored with a dye and its dispersion within the uterine cavity was recorded by a video camera. The results demonstrated, for the first time, the importance of having a gas phase in the catheter load. The resulting air bubbles within the uterus were carried upward towards the fundus by buoyant forces, thereby dragging behind them the transferred liquid which contained the embryos. This could be expected to substantially increase the probability for the embryos to be present near the fundal wall at the time window for implantation. There was also evidence of a dependency of the rate of injection upon the catheter load into the uterus: a low speed generated several air bubbles which led to more of the transferred liquid being carried towards the fundal end, thus possibly enhancing the potential for implantation.
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Affiliation(s)
- Osnat Eytan
- Ultrasound Unit in Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 64239, Israel.
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32
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Flisser E, Grifo JA. Is what we clearly see really so obvious? Ultrasonography and transcervical embryo transfer—a review. Fertil Steril 2007; 87:1-5. [PMID: 17094986 DOI: 10.1016/j.fertnstert.2006.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 05/08/2006] [Accepted: 05/08/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To critically review the role of ultrasound-guided embryo transfer (ET) and its influence on the outcome of in vitro fertilization (IVF). DESIGN Medline review of published manuscripts. RESULT(S) Studies evaluating the role of ultrasound-assisted ET have had mixed results, and although meta-analysis of prospective trials suggests an improvement in outcome, limitations in study design may overstate the effect of ultrasonography. Other ET techniques may eliminate the advantages provided by ultrasonography, limiting its benefit to specific clinical scenarios. However, because no trial has demonstrated an adverse effect and because cases that may benefit from its use often cannot be predicted reliably, the routine application of ultrasonography can be justified.
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Affiliation(s)
- Eric Flisser
- New York University Fertility Center, New York University School of Medicine, New York, New York 10016, USA.
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33
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Cavagna M, Contart P, Petersen CG, Mauri AL, Martins AMC, Baruffi RLR, Oliveira JBA, Franco JG. Implantation sites after embryo transfer into the central area of the uterine cavity. Reprod Biomed Online 2006; 13:541-6. [PMID: 17007675 DOI: 10.1016/s1472-6483(10)60642-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A total of 63 pregnancies (47 singleton, 15 twin, 1 triplet) from intracytoplasmic sperm injection cycles were analysed. In all embryo transfers, the catheter was introduced into the endometrial cavity guided by abdominal ultrasound, with the catheter tip placed at the middle point of the endometrial cavity. Gestational sacs (GS) were located 21-24 days after transfer (gestational age=5 weeks) by two-dimensional and three-dimensional transvaginal ultrasound. The uterine cavity was divided into three parts: upper, middle and lower. Furthermore, the upper region was subdivided into right, middle and left areas, and the middle region was subdivided into right and left areas. The frequency of gestational sacs in each area was evaluated. In singleton pregnancies 66.0% (31/47) of the GS were detected in the upper region, 29.8% (14/47) in the middle region and 4.2% (2/47) in the lower region. In multiple pregnancies (twins and triplet) 45.5% (15/33) of the GS were detected in the upper region, 51.5% (17/33) in the middle region and 3.0% (1/33) in the lower region. In conclusion, the results demonstrate that when embryos are transferred to the central area of the uterine cavity there is an increase in implantation rate in the middle region compared with the rate expected in naturally conceived pregnancies (9-15%).
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Affiliation(s)
- M Cavagna
- Center for Human Reproduction Prof. Franco Junior, Av. Prof. João Fiusa, 689-CEP 14025-310, Ribeirão Preto, SP, Brazil
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34
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Abstract
PURPOSE OF REVIEW Embryo transfer is arguably the most critical step in assisted reproduction. The purpose of this article is to review the different aspects of the procedure in the light of recent evidence. RECENT FINDINGS Randomized trials have shown that significantly higher pregnancy rates are obtained when embryo transfer is performed under ultrasound guidance, the embryos are deposited in the middle part of the uterine cavity, an atraumatic technique is used and when low-dose aspirin is routinely administered following the procedure. Blood in the catheter and leaving the embryos inside it for more than 120 s diminish the pregnancy rate significantly. Air in the catheter, immediate removal of the catheter, performing two transfers in the same cycle, prolonged bed rest, sexual intercourse after embryo transfer or the use of sildenafil do not affect the results. Based on currently available evidence, Cochrane reviews have concluded that the live birth rate is not increased by delaying embryo transfer from day two to three or to the blastocyst stage, and that single embryo transfer leads to lower live birth rates than the transfer of two embryos. The value of a mock transfer a few days before the actual procedure has been challenged as the position of the uterus may change. The effect of holding the cervix with a volsellum, routinely administering antibiotics and the superiority of one catheter over the others is still to be determined. SUMMARY Recent studies confirm the importance of the various aspects of embryo transfer. More randomized studies are needed to further evaluate them.
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Affiliation(s)
- Hassan N Sallam
- Department of Obstetrics and Gynaecology, University of Alexandria and Alexandria Fertility Center, Alexandria, Egypt.
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35
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Silberstein T, Trimarchi JR, Shackelton R, Weitzen S, Frankfurter D, Plosker S. Ultrasound-guided miduterine cavity embryo transfer is associated with a decreased incidence of retained embryos in the transfer catheter. Fertil Steril 2005; 84:1510-2. [PMID: 16275257 DOI: 10.1016/j.fertnstert.2005.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Revised: 06/03/2005] [Accepted: 06/03/2005] [Indexed: 10/25/2022]
Abstract
After initiating a policy of ultrasound-guided miduterine cavity embryo transfer (ET) on August 1, 2001, the incidence of retained embryos in the transfer catheter declined significantly from 4.2% (46 of 1,101 ETs) during the time interval January 1, 2000 to July 31, 2001, to 0.7% (6 of 908 ETs) during the time interval August 1, 2001 to December 31, 2002. Blood on the transfer catheter (38% vs. 19%) occurred with significantly greater frequency at ET in which embryos were retained; ETs of > or =4 embryos were more likely to be associated with retained embryos than ETs of <4 embryos (3.7% vs. 2.2%), and both the clinical pregnancy rate (PR) and implantation rate (IR) were lower when embryo retention occurred at ET than they were when embryos were not retained (25% vs. 34% clinical PR; 12% vs. 19% IR).
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Affiliation(s)
- Tali Silberstein
- Division of Biology and Medicine, Brown Medical School, Providence, Rhode Island, USA
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36
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Gergely RZ, DeUgarte CM, Danzer H, Surrey M, Hill D, DeCherney AH. Three dimensional/four dimensional ultrasound-guided embryo transfer using the maximal implantation potential point. Fertil Steril 2005; 84:500-3. [PMID: 16084896 DOI: 10.1016/j.fertnstert.2005.01.141] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2004] [Revised: 01/19/2005] [Accepted: 01/19/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the use of maximal implantation potential (MIP) point in conjunction with a 3D/4D ultrasound in order to facilitate embryo transfers and potentially improve pregnancy rate. DESIGN Retrospective, observational study. SETTING IVF Center. PATIENT(S) Between October 1, 2002, and August 27, 2004, 1,222 patients who underwent 3D/4D-ultrasound guided embryo transfers. INTERVENTION(S) Ultrasound-guided embryo transfer using a 3D/4D ultrasound machine and the MIP point. MAIN OUTCOME MEASURE(S) Procedure feasibility with improved visibility. RESULT(S) Embryo transfers were performed at the MIP point and the pregnancy rate was 36.66% (average patient age, 37.6 years). Physicians reported improved visualization and a greater accuracy in the placement of embryos within the uterine cavity. CONCLUSION(S) The MIP point can be immediately identified and individualized for each patient. Embryo transfers at the MIP were associated with good implantation and pregnancy rates.
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Affiliation(s)
- Robert Z Gergely
- 3D Sonography Center of Beverly Hills, Beverly Hills, CA 90210, USA.
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37
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Shamonki MI, Schattman GL, Spandorfer SD, Chung PH, Rosenwaks Z. Ultrasound-guided trial transfer may be beneficial in preparation for an IVF cycle. Hum Reprod 2005; 20:2844-9. [PMID: 16006476 DOI: 10.1093/humrep/dei139] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The objective of this study is to determine if ultrasound-guided trial transfer (UTT) in the office in preparation for an IVF cycle can be utilized as an alternative and/or adjunct to ultrasound-guided embryo transfer (UGET). METHODS Patients planning to undergo an IVF cycle at an academic centre were included. Each patient underwent an UTT in the office by the same practitioner. The difference in length (DL), if any, was measured from the perceived top of the uterine cavity (catheter tip) to the actual cavity apex as visualized by ultrasound. RESULTS Of the 64 patients enrolled, 19 patients (29.7%) had a measurable DL, of which 14 (21.9%) had a DL exists 0.5 cm, and nine (14.1%) had a DL exists 1.0 cm. Significant differences were noted between patients when comparing DL to previous pregnancy status and the total cavity depth (sounding depth + DL) (P < 0.05). CONCLUSION UTT in the office setting appears to be beneficial in preparation for an IVF cycle with embryo transfer.
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Affiliation(s)
- Mousa I Shamonki
- The Center for Reproductive Medicine and Infertility, Weill Medical College of Cornell University and The New York Presbyterian Hospital, New York 10021, USA
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38
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Urman B, Yakin K, Balaban B. Recurrent implantation failure in assisted reproduction: how to counsel and manage. A. General considerations and treatment options that may benefit the couple. Reprod Biomed Online 2005; 11:371-81. [PMID: 16176681 DOI: 10.1016/s1472-6483(10)60846-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recurrent implantation failure is a distressing phenomenon, both for the infertile couple and for the physician responsible for their treatment. Aetiology is often not clear and treatment options are vague. Particularly when transferred embryos are of good quality, recurrent implantation failure may be attributed to less than optimal embryo transfer technique, pathological lesions of the uterine cavity, the presence of hydrosalpinges, fibroids and endometriosis. Poor embryo quality, especially when repetitive, is a major impediment to successful implantation and cannot be corrected at the present time. Molecular abnormalities at the endometrial level and abnormal embryo-endometrium dialogue may be responsible for some cases of recurrent implantation failure. Furthermore, there may be over- or under-expressed genes that may be related to successful implantation. At the present time, the physician confronted with a couple presenting with recurrent implantation failure should discuss openly the potential causes of this phenomenon, with special emphasis on correctable causes, and offer remedies that are evidence based.
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Affiliation(s)
- Bulent Urman
- Assisted Reproduction Unit, American Hospital of Istanbul, Turkey.
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39
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Levi Setti PE, Colombo GV, Savasi V, Bulletti C, Albani E, Ferrazzi E. Implantation Failure in Assisted Reproduction Technology and a Critical Approach to Treatment. Ann N Y Acad Sci 2004; 1034:184-99. [PMID: 15731311 DOI: 10.1196/annals.1335.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In this article, we review the literature and our personal experience regarding the many factors that appear to influence implantation rate. Oocyte quality, as determined by patient age and aneuploidies, probably plays a major role in RIF. However, a panoply of other factors have been brought under investigation, quite often with contradictory results and additional intriguing questions to be studied. Infections of the vagina, cervix, and endometrium, the role of mucus aspiration and washing of the cervix on transfer, the role of catheter guidance for a correct transfer and potion of embryos, the effect of mock transfer, and the role of hysteroscopy and its timing before transfer procedures are analyzed both as a review of the literature and as opinions and data from our experience. Many of these factors are interlaced and from the apparently simple issue of trauma, to infections and immune modulation of hatching and implantation, a biological continuum can easily be identified. The impact of abnormalities of the immune system and of homeostasis abnormalities is also covered in a brief overview of reported works and our experience. These latter areas probably constitute the common biological background of all other external factors that, however, the skilled must equip themselves for improving implantation success.
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Affiliation(s)
- P E Levi Setti
- Operative Unit of Reproductive Medicine, Humanitas Clinical Institute, Via Manzoni 56, 20089 Rozzano (Milano), Italy.
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40
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Oliveira JBA, Martins AMVC, Baruffi RLR, Mauri AL, Petersen CG, Felipe V, Contart P, Pontes A, Franco Júnior JG. Increased implantation and pregnancy rates obtained by placing the tip of the transfer catheter in the central area of the endometrial cavity. Reprod Biomed Online 2004; 9:435-41. [PMID: 15511345 DOI: 10.1016/s1472-6483(10)61280-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The influence of endometrial cavity length (ECL) on implantation and pregnancy rates after 400 embryo transfers was studied prospectively in a population with the indication of IVF/intracytoplasmic sperm injection (ICSI). The tip of the transfer catheter was placed above or below the half point of the ECL in a randomized manner. Two analyses were performed: (i) absolute position (AP); embryo transfers were divided into three groups according to the distance between the end of the fundal endometrial surface and the catheter tip (DTC - distance tip catheter): AP1 (n = 212), 10-15 mm; AP2 (n = 158), 16-20 mm; and AP3 (n = 30), > or =21 mm. (ii) relative position (RP)--embryo transfers were divided into four groups according to their RP [RP = (DTC/ECL) x 100]: RP1 (n = 23), < or =40%; RP2 (n = 177), 41-50%; RP3 (n = 117), 51-60%; and RP4 (n = 83), > or =61%. Analysis based on relative distance revealed significantly higher implantation and pregnancy rates (P < 0.05) in more central areas of the ECL. However, analysis based on absolute position did not reveal any difference. In conclusion, the present results demonstrated that implantation and pregnancy rates are influenced by the site of embryo transfer, with better results being obtained when the catheter tip is positioned close to the middle area of the endometrial cavity. In this respect, previous analysis of the ECL is the fundamental step in establishing the ideal site for embryo transfers.
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Affiliation(s)
- J B A Oliveira
- Centre for Human Reproduction Sinhá Junqueira, Rua D. Alberto Gonçalves, 1500-CEP 14085-100, Ribeirão Preto, SP-Brazil
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