Optimizing the technique of embryo transfer

Steps forward in embryo transfer technique: a retrospective study comparing direct versus afterload catheters at different time frames

PURPOSE

To assess whether embryo transfer (ET) technique can influence the clinical pregnancy rate (CPR) and its correlation with the embryo transfer difficulty.

DESIGN

This single center retrospective cohort analysis of fresh and frozen single blastocyst transfers performed between January 2016 and December 2021 included fresh and frozen single blastocyst transfers performed during the study timeframe. Direct technique was the only one used from January 2016 to September 2017. From September 2017 to March 2019, the choice between the two techniques was given by randomization, due to a clinical trial recruitment. From April 2019, only the afterload technique was used. Preimplantation genetic testing cycles and gamete donation procedures and cycles performed with external gametes or embryos were excluded. CPR was the primary outcome, while difficult transfer rate the secondary one. Univariate and multivariate logistic regressions were performed.

RESULTS

During the period, 8,189 transfers were performed. CPR of the afterload group resulted significantly higher compared to the direct group (44.69% versus 41.65%, OR 1.13, 95% CI 1.02-1.25, p = 0.017) and the rate of difficult transfers two-thirds lower (9.06% versus 26.85%, OR 0.27, 95% CI 0.24-0.31, p < 0.001).

CONCLUSION

Our study demonstrated that CPR is significantly affected by the ET technique. In particular, with the afterload protocol, both CPR and easy transfer rates increased.

TRIAL REGISTRATION

http://clinicaltrials.gov registration number: NCT05364528, retrospectively registered on 3rd of May 2022.

Presence of Adenomyosis Impairs Clinical Outcomes in Women Undergoing Frozen Embryo Transfer: A Retrospective Cohort Study

(1) Background: The presence of adenomyosis among pregnant patients has been associated with a higher incidence of miscarriage and pregnancy complications. Although the role of adenomyosis in women undergoing in vitro fertilization (IVF) was investigated in several studies and demonstrated a potentially detrimental effect on live birth rates following IVF, most of them were small studies in which the adenomyosis diagnosis was not confirmed based on solid ultrasonographic criteria. (2) Methods: 3503 patients undergoing their first blastocyst frozen transfer through a hormonal replacement (HRT) FET cycle. Among them, 140 women had a confirmed diagnosis of adenomyosis based on the MUSA criteria. (3) Results: Adenomyosis patients were more likely to proceed with deferred FET compared with no-adenomyosis women (p = 0.002) and were significantly more likely to be treated with GnRH agonist pre-treatment (2 months) (p < 0.001). The presence of adenomyosis significantly decreased the clinical pregnancy rates (aOR 0.62, 95% CI: 0.39-0.98, p = 0.040) and live birth rates (aOR 0.46, 95% CI: 0.27-0.75, p = 0.003) and significantly increased the miscarriage rates (aOR 2.13, 95% CI: 0.98-4.37, p = 0.045). Multivariable logistic regression adjusting for age, autologous or donor oocytes, PGT-A, deferred FET, serum progesterone levels the day before FET, GnRH agonist pre-treatment, number of embryos transferred, and adenomyosis demonstrated that the use of the GnRH agonist protocol did not decrease or increase the miscarriage rate, clinical pregnancy rate, or live birth rate. (4) Conclusions: The presence of adenomyosis had a significant negative impact on the clinical outcomes of patients undergoing FET and was associated with higher miscarriage, lower clinical pregnancy, and live birth rates. GnRH agonist pre-treatment does not appear to improve clinical outcomes.

Embryo transfer learning using medical simulation tools: a comparison of two embryo transfer simulators

INTRODUCTION

Embryo transfer(ET) is one of the main procedures to become pregnant by assisted reproductive technology(ART). Simulation training is a way to improve the skills of clinicians. The objective of this study was to evaluate the interest of trainees in learning embryo transfer using simulators.

MATERIAL AND METHODS

An observational study was conducted at the University hospital-based research center. Trainees, comprising midwives and resident or graduated gynecologists, who attended the medical training for infertility and ART in June 2019, were included. They trained on two ET simulators (Simulator A and B) and complete an anonymously online questionnaire. A sub-group analysis focusing on graduated gynecologists not performing ET in current practice, was performed.

RESULTS

Thirty-two trainees were included. Trainees felt that ET simulators should be used in medical education to promote learning how to perform the ET procedure (n=26, 81.3% for Simulator A and n=21, 65.5% for Simulator B; p=0.31). The use of both simulators improved the level of self-confidence (81.3% and 75.0% respectively; p=0.55). Significant differences in the global and in the subgroup analysis (n=24) in favor of Simulator A were observed regarding learning the precision of the ET procedure (p<0.01), the pathway to introduce the catheter into the uterine cavity (p<0.05), and the guidance for proper placement of the catheter into the uterine cavity (p=0.03). In the subgroup analysis of graduated gynecologists not performing ET in current practice, Simulator A was found more realistic for the visualization of the introduction of the catheter into the uterine cavity (p=0.01) and more useful to learn about difficult cases (p=0.03).

CONCLUSION

Students expressed a high level of interest in ET simulators to improve their skills. Although the simulators displayed some differences regarding learning the precision of the ET procedure, both improved the level of self-confidence. This new learning method needs to be further developed in order to offer to trainees the most realistic simulators.

TRIAL REGISTRATION

This study was approved for publication by the Ethics Review Committee of the Cochin University Hospital (CLEP) (n° AAA-2020-08016) retrospectively registered.

Comparison of pregnancy outcomes of cervical mucus washing with physiologic saline solution or G-Rinse medium solution, in elective single-embryo transfers

AIM

To compare the pregnancy outcomes between physiologic saline and G-Rinse medium solution for cervical mucus washing, in fresh elective single-embryo transfers (ET) in women under the age of 37.

MATERIAL AND METHODS

This was a retrospective data analysis performed in a single in vitro fertilization (IVF) center between February 2018 and November 2021. Women younger than 37 years who underwent single elective ET were included and all women had anti-Mullerian hormone (AMH) levels ≥ 1.5 ng/ml. Age, body mass index (BMI), AMH levels, and pregnancy outcomes as clinical pregnancy rate (CPR) and live birth rate (LBR) were analyzed.

RESULTS

Study population consisted of 75 women in the G-Rinse medium solution group and 97 women in the physiologic saline group. Clinical pregnancy rate was 58.7% and 61.9% in the G-Rinse medium solution group and saline group, respectively (p = 0.673), and LBR was calculated as 41.3% and 47.4% in the G-Rinse medium solution group and saline group, respectively (p = 0.430). A log-binomial regression model was used and the model was adjusted for BMI to evaluate the effect of the cervical mucus washing method on the pregnancy outcomes. There was an estimated 5% decrease in the relative risk for CPR in the G-Rinse medium solution group compared to the saline group (95% CI: 0.74 to 1.2, p = 0.673). There was an estimated 13% reduction in the relative risk for LBR in the G-Rinse medium solution group compared to the saline group (95% CI: 0.62 to 1.23, p = 0.430). They were both statistically not significant.

CONCLUSION

In our study, the replacement of using G-Rinse medium solution to physiologic saline solution for cervical cleaning did not change CPR and LBR outcomes. Using physiologic saline solution can be a good alternative approach for ectocervical washing during embryo transfer in selected population because of its lower costs, easy accessibility, and common use.

Effect of retained embryos on pregnancy outcomes of in vitro fertilization: a matched retrospective cohort study

OBJECTIVES

To explore the incidence of retained embryos (REs) in embryo transfer (ET) cycles and its effects on pregnancy outcomes in women undergoing in vitro fertilization (IVF).

METHODS

This was a matched retrospective cohort study involving 29,160 ET cycles conducted from March 2016 to February 2021, in which ET cycles without RE were matched to the RE group at a 2:1 ratio. Clinical pregnancy, implantation, miscarriage, and live birth rates were compared between the with-RE and without-RE groups.

RESULTS

Our study showed that the overall incidence of REs was 0.33% (95/29,160). There was a statistically significant difference in RE rate among the operators (P < 0.001), suggesting that the embryo retention rate may be affected by the individual operator. A total of 95 repeated ET cycles due to RE were included in the study group, and 190 ET cycles without RE were matched to the study group (1:2). There were no significant differences between the RE and matched groups in terms of implantation rate (35.6 vs. 38.0%; P = 0.608), clinical pregnancy rate (47.4 vs. 54.7%; P = 0.240), biochemical pregnancy rate (5.3 vs. 4.7%; P = 0.846), miscarriage rate (11.1 vs. 9.6%; P = 0.781), ectopic pregnancy rate (2.2 vs. 1.9%; P = 1.000) or live birth rate (41.1 vs. 48.9%; P = 0.208).

CONCLUSIONS

The present findings demonstrated that immediate retransfer of REs did not significantly affect IVF outcomes, which may provide counselling information for patients when REs are identified and ET is reattempted. The incidence of REs was associated with the operator who expelled the embryos from the catheter. Attention to detail and frequent assessment of the operator's technique may facilitate avoidance of embryo retention.

Ectopic pregnancy risk factors in infertile patients: a 10-year single center experience

The present retrospective study included both intrauterine insemination and in vitro assisted reproductive technologies (ART) procedures performed from January 2009 to December 2018 at a tertiary-care Fertility Centre. The purpose was to assess the incidence of ectopic pregnancy (EP) in infertile population who undergoes ART and to identify any risk factor impacting the occurrence of EP after ART. Among 27,376 cycles, 7352 pregnancies were achieved, of which 132 were EPs, the 1.80% (95% CI 1.5-2.1) of all pregnancies. In fresh embryo transfer cycles, a history of prior pelvic adhesions showed the greatest impact on the incidence of EP (aOR 2.49 95% CI 1.53-4.07 p < 0.001). Other factors associated with EP incidence were also identified, such as female age, basal FSH, the transfer of blastocyst embryos and difficulties during the embryo transfer procedure. In frozen embryo transfer cycles, the only factor influencing the incidence of EP was anti Müllerian hormone (AMH) serum concentration (aOR 0.81 95% CI 0.65-1.00, p = 0.048). To conclude, the incidence of EP observed was comparable to that reported after natural conception. On the other hand, pre-existing risk factors, traditionally more common in infertile population, appeared to influence the incidence of EP and should thus be modified if possible.

Uterine factors modify the association between embryo transfer depth and clinical pregnancy

The embryo transfer depth may affect the chance of pregnancy. However, embryo dislodging caused by uterine contraction may occur after the transfer. The aim of the retrospective study was to investigate whether the factors associated with uterine contractilities, such as endometrial thickness and progesterone elevation, affect the association between transfer depth and implantation. A total of 7849 fresh transfer cycles on conventional stimulation in a single in vitro fertilization (IVF) center during the period 2013–2015 was reviewed. Patients were categorized according to quartiles of embryo transfer depth (≤ 9 mm, n = 1735, 9.1–11 mm, n = 2557, 11.1–14 mm, n = 1933, ≥ 1.4 mm, n = 1624, respectively). Adjusted for confounding factors, the adjusted odds ratio (aOR) (95% confidence interval, CI) for clinical pregnancy was 0.90 (0.79–1.02), 0.86 (0.74–0.99), and 0.70 (0.60–0.82) respectively in quartiles 2 through 4, comparing with quartile 1. However, the aORs were significantly increased when the endometrial thickness was < 8 mm. In comparison with that in the cycles with a normal endometrial thickness (8–11 mm), the aORs comparing quartiles 2 through 4 with quartile 1 in the cycles with an endometrial thickness < 8 mm increased from 0.78 (95% CI 0.65–0.93), 0.79 (95% CI 0.65–0.97), and 0.64 (95% CI 0.51–0.81) to 1.73 (95% CI 1.21–2.47), 1.04 (95% CI 0.69–1.56), and 1.45 (95% CI 0.91–2.31), respectively. In the cycles with elevated progesterone and blastocyst stage transfer, the aORs comparing quartiles 4 with quartile 1 decreased from 0.73 (95% CI 0.62–0.87) and 0.74 (95% CI 0.63–0.87) to 0.58 (95% CI 0.40–0.84) and 0.42 (95% CI 0.25–0.73) than those in the cycles without. However, only blastocyst transfer showed a significant interaction with transfer depth (p = 0.043). Our data suggested that endometrial thickness and blastocyst transfer significantly affect the association between embryo transfer depth and clinical pregnancy.

Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses

BACKGROUND

Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists.

OBJECTIVE AND RATIONALE

We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes.

SEARCH METHODS

We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses.

OUTCOMES

Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs.

WIDER IMPLICATIONS

Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.

Improving IUI success by performing modified slow-release insemination and a patient-centred approach in an insemination programme with partner semen: a prospective cohort study

Background

Pregnancy rates after in vitro fertilisation (IVF) treatment continue to improve, while intrauterine insemination (IUI) programmes show no such trend. There is a need to improve success rates with IUI to retain it as a viable option for couples who prefer avoiding IVF as a first line treatment.

Objective

To investigate if a modified slow-release insemination (SRI) increases the clinical pregnancy rate (CPR) after intrauterine insemination (IUI) with partner semen.

Materials and Methods

This was a prospective cohort study in a Belgian tertiary fertility centre. Between July 2011 and December 2018, we studied data from an ongoing prospective cohort study including 989 women undergoing 2565 IUI procedures for unexplained or mild/moderate male infertility. These data were analysed in order to study the importance of different covariates influencing IUI success. Generalised estimating equations (GEEs) were used for statistical analysis. Results of two periods (2011-2015, period 1 and 2016-2018, period 2) were examined and compared. From January 2016 (period 2) onwards, a standardised SRI procedure instead of bolus injection of sperm was applied. The primary outcome parameter was the difference in clinical pregnancy rate (CPR) per cycle between period 1 (bolus IUI) and period 2 (modified SRI). Secondary outcome results included all other parameters significantly influencing CPR after IUI.

Results

Following the application of modified SRI the CPR increased significantly, from 9.03% (period 1) to 13.52% (period 2) (p = 0.0016). Other covariates significantly influencing CPR were partner’s age, smoking/ non-smoking partner, BMI patient, ovarian stimulation protocol and Inseminating Motile Count (after semen processing).

Conclusion

The intentional application of modified slow-release of processed semen appears to significantly increase CPRs after IUI with homologous semen. Future studies should investigate whether SRI, patient-centred measures, or a combination of both, are responsible for this improvement.

The Role of Transvaginal Ultrasound Guided Embryo Transfer to Improve Pregnancy Rate in Obese Patients Undergoing Intracytoplasmic Sperm Injection

Objective

To evaluate the effectiveness of transvaginal ultrasound (TVUS) versus the transabdominal ultrasound (TAUS) guided embryo transfer (ET) in obese patients undergoing Intracytoplasmic sperm injection (ICSI).

Design

A prospective randomized controlled trial.

Setting

University hospital.

Patient(s)

Eight hundred participants with BMI ≥30 received the long agonist protocol. They were randomized into 2 equal groups of 400 patients. Each group had either TAUS guided ET or TVUS guided ET.

Main Outcome Measure(s)

Our primary outcomes were clinical pregnancy rate, degree of patient pain assessed by visual analogue scale (VAS). The secondary outcomes were live birth rate, implantation rate, miscarriage and chemical pregnancy rates, duration of ET.

Result(s)

Our results showed a significant higher chemical and clinical pregnancy rates in the TVUS group in comparison to TAUS group (45.3% vs. 38.3%, p=0.045) and (37.8% vs. 30.8%, p=0.044) respectively. There was tendency for increased live birth rates in the TVUS group however it did not reach statistical significance (50.2% vs. 44.8%). The VAS of the pain was significantly less in TVUS group in comparison to the TAUS group (2.1 ±0.7 vs. 4.5 ±1.3), also abdominal discomfort was significantly less in TVUS group in comparison to the TAUS group (13% vs. 58%) p= value 0.0001.

Conclusion(s)

This study showed superior role of TVUS guided ET over TAUS regarding less pain and better pregnancy and live birth rates in obese participants.

Clinical Trial Registration Number

Clinical trial. Gov identifier NCT03473028.

One step further: randomised single-centre trial comparing the direct and afterload techniques of embryo transfer

STUDY QUESTION

What are the differences in ease of use between two different embryo transfer (ET) techniques: the preload direct approach and the afterload approach.

SUMMARY ANSWER

The afterload technique seems to reduce the rate of difficult ETs.

WHAT IS KNOWN ALREADY

Numerous published trials now document that the ET procedure has an impact on pregnancy and delivery rates after IVF. Difficult transfers should be avoided, as they reduce implantation and pregnancy rates. Preload direct ETs with soft catheters under ultrasound guidance is currently considered the best procedure. However, when using soft catheters, it is not known which technique is preferable or which one should be implemented to reduce the operator factor.

STUDY DESIGN, SIZE, DURATION

This prospective randomised unblinded controlled clinical trial, included 352 ultrasound-guided ETs assigned to either direct ET or afterload ET, between September 2017 and March 2019. The sample size was calculated based on the historical rate of difficult ETs encountered between 2014 and 2015 with a direct ET procedure.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were women 18-38 years old, with BMI between 18 and 28, receiving a single-thawed blastocyst transfer. The exclusion criteria were use of testicular sperm and preimplantation genetic testing (PGT) cycles. The primary outcome was the rate of difficult or suboptimal transfers defined as: advancement of the outer sheath (specific for the direct transfer), multiple attempts, use of force, required manipulation, use of a stylet or tenaculum, dilatation, or use of a different catheter. The secondary outcome was clinical pregnancy rate.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 352 frozen ETs were randomised, with 176 patients in each group. The two arms were homogeneous for female and male age, female BMI, duration of infertility, secondary infertility, previous deliveries or miscarriages, myomas, previous surgery to the uterine cavity, cycle day at ovulation trigger, freeze all cycles, first transfers, indication for treatment, endometrial preparation protocol and duration, endometrial thickness, and blastocyst grade at vitrification. Across the entire population, 85 (24.1%) ETs were defined as difficult. The rate of difficult transfers was significantly higher in the direct ET group than in the afterload group: 68 (38.6%) versus 17 (9.7%), respectively (OR 0.17, 95% CI 0.09-0.30, P < 0.001). The mean percentage in the rate of difficult transfers per operator was 22.5% (SD ± 14.5%), of which 36.1% (SD ± 23.4%) were in the direct group compared with 8.6% (± 8.2%) in the afterload group (P < 0.001). The difficult transfer rate among operators varied from 0 to 43.8% (0-77.8% in the direct group and 0 to 25.0% in the afterload group). The clinical pregnancy rates (42.0% vs 48.3%, P = 0.239 in the direct and afterload groups, respectively) were not significantly different between the groups.

LIMITATIONS, REASONS FOR CAUTION

There were 18 experienced operators who participated in the trial. Conclusions about the pregnancy rate should not be generalised, since the sample analysis was not performed on this outcome and, although clinically relevant, the difference was not significantly different.

WIDER IMPLICATIONS OF THE FINDINGS

The rate of difficult transfers was significantly higher in the direct ET group compared with the afterload ET group, although a wide variation was observed among operators. Further studies regarding the association between transfer technique and ART outcomes are required.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was sought and there are no competing interests.

TRIAL REGISTRATION NUMBER

NCT03161119.

TRIAL REGISTRATION DATE

5 April 2017.

DATE OF FIRST PATIENT'S ENROLMENT

26 September 2017.

A fine tuning of embryo loading technique by eliminating the air bubble in the outer sheath of embryo catheter among women undergoing IVF treatment

OBJECTIVES

The role of air bubbles in bracketing the embryo-containing medium in inner catheter during embryo transfer (ET) has already been established. However, the role of air bubbles in outer catheter (OC) during implantation is yet to be determined. This study aimed to compare the implantation rates between women who have undergone ET with or without ASP (Vitrolife^®; Sweden), a medium use for oocyte retrieval and rinsing in OC embryo catheter. The purpose of introducing the ASP medium to the OC was to eliminate air bubbles in that space during implantation.

METHODS

A total of 312 women were randomly divided into two groups with 156 participants each group. In Group A, ASP medium was used during ET, whereas in Group B, no ASP medium was utilized. Positive implantation was defined as serum beta-hCG level >5 mIU/mL taken on the 7th day following ET.

RESULTS

The average age of the majority of the participants was 30-39 years and had at least 4-5 years of subfertility. The unexplained subfertility was the prominent cause of ET failure in both groups. In most of the participants in both groups, ET was done using fresh embryo cycles with good to excellent embryo grades. After the ASP medium was manipulated in the OC in both groups, the positive implantation rate was not different in both groups (p>0.05).

CONCLUSIONS

The elimination of air bubbles in OC by using the ASP medium during ET did not confer an additional benefit nor exert a negative impact on implantation rate.

The predictive value of serial serum estradiol and serial endometrial volume on endometrial receptivity on assisted reproductive technology cycles

Background

Diagnosis of endometrial receptivity is still unclear and conflicting. Despite advances in embryo development during assisted reproductive technologies (ART) cycles, the intricate process of implantation is still matter for debate and research.

Materials and methods

Prospective case control of 169 subjects during ovarian controlled stimulation for ART. Endometrial receptivity assessment to predict clinical pregnancy with serial continuous biochemical (serum estradiol) and biophysical (endometrial volume and adjusted endometrial volume) parameters were used. Both parameters were compared between negative and positive outcome in terms of clinical pregnancy.

Results

No statistical difference was noted between the two groups in terms of demographics and ART procedures and scores. Serum estradiol was significantly higher in the positive group from day 8 after ovarian controlled stimulation. Endometrial volume and adjusted endometrial volume were significantly higher in the positive group as soon as day 6 of ovarian controlled stimulation.

Conclusions

Continuous serum estradiol and 3D endometrial volume and adjusted endometrial volumes may reflect endometrial changes during ART procedures and provide a useful real time tool for clinicians in predicting endometrial receptivity.

A New Concept in Minimally Invasive Embryo Transfer

Considerable variation in embryo transfer (ET) catheter types, diverging opinions on their quality and functionality, complications following the insertion of catheters, low efficiency of the application of ET methods in humans, and their widely varying efficiency in animals demonstrate the need to improve ET methods and to look for new types of catheters. Such an opportunity is offered by the introduction of catheters made of new-generation biomaterials. This study was aimed to introduce a new generation of biomaterials into reproductive biotechnology. New-generation materials were compared with materials that have been used for many years, and the functionality of newly produced catheters was compared in vivo. Five types of biomaterials were tested: polycaprolactone (PCL), dibutyryl chitin (DBC), polypropylene (PP), polyethylene (PE) and polylactide (PLA). The study was carried out in two stages. Firstly, the basic utility parameters such as geometric stability, surface structure and catheter resistance were evaluated. Subsequently, the biocompatibility of selected biomaterials in embryo cultures was examined, and the development potential of the obtained blastocysts was evaluated. In the second stage, in vivo with live animals, the biomaterials were tested for biocompatibility and the obtained catheters were examined for their ET functionality. Efficiency with the use of the newly produced catheters was determined, the quality of the blastocysts obtained after embryo culture in the uterus was assessed, and oviducts were subjected to histopathological examination after embryo transfer. Of the tested biomaterials, only polyethylene (PE) showed adequate biological and material properties and proved suitable for production of ET catheters.

Continuous endometrial volumetric analysis for endometrial receptivity assessment on assisted reproductive technology cycles

BACKGROUND

Human implantation is a complex process requiring synchrony between a healthy embryo and a functionally competent or receptive endometrium. In order to assess endometrial receptivity in Assisted Reproductive Technology (ART) cycles serial evaluation of endometrial volumetric analysis may have a predictive value on a positive outcome.

METHODS

Serial 3D transvaginal ultrasound performed in women on ART cycle to evaluate embryo implantation predictors. Prospective case control study of 169 subjects were assessed. Endometrial pattern, thickness, volume and adjusted endometrial volume (ratio between endometrial volume and uterine volume) was performed to all subjects on a continuous process from baseline, during controlled ovarian stimulation, trigger day with human chorionic gonadotropin hormone (hCG) and at embryo transfer day.

RESULTS

Demographics and ART procedures and scores, was similar between the two groups. Endometrial morphology also showed no difference between the two groups. Endometrial volume and adjusted endometrial volume was significantly higher in the positive group as soon as day 6 of ovarian controlled stimulation.

CONCLUSIONS

Serial 3D endometrial volume and adjusted endometrial volumes provides a predicting clinical tool enhancing elective embryo transfers in fresh ART cycle. Thus providing a non-invasive continuous technique for endometrial receptivity assessment that reflects endometrial changes during ART procedures.

Embryo location in the uterus during embryo transfer: An in vitro simulation

Objective

To evaluate the location of transferred embryos under various parameters during embryo transfer in in vitro fertilization (IVF) by applying an in vitro experimental model for embryo transfer (ET).

Methods

Mock ET simulations were conducted with a laboratory model of the uterine cavity. The transfer catheter was loaded with a sequence of air and liquid volumes, including development-arrested embryos donated by patients. The transfer procedure was recorded using a digital video camera. An orthogonal design, including three independent variables (uterine orientation, distance of the catheter tip to the fundus, and injection speed) and one dependent variable (final embryo position), was applied.

Results

The uterine cavity was divided into six regions. The distribution of the transferred matter within the uterine cavity varied according to the uterine orientation. Medium speed-injected embryos were mostly found in the static region while fast- and slow-speed injected embryos were mostly found in the fundal region and the cervical-left region, respectively. The possibility of embryo separation from the air bubble increased from 11.1% in slow injection cases to 29.6% and 48.1% in medium and fast injection cases, respectively.

Conclusion

The experimental model provides a new method for investigating ET procedures. Fast injection of embryos into a retroverted uterus may be more likely to result in embryo separation from the air bubble.

Does the Time of Starting Progesterone Luteal Support Affect Embryo Transfer in Long Agonist Protocol Downregulated ICSI Cycles? A Randomized Controlled Trial

The aim of this study was to compare the effects of starting progesterone (P4) luteal support (LS) on day of egg retrieval (ER) or day of embryo transfer (ET) on the ratio of difficult ET and cycle outcome. This was a RCT ( ClinicalTrials.gov Identifier: NCT03040830) carried out at Mansoura Integrated Fertility Center (MIFC), Mansoura, Egypt, from November 2015 to January 2017. A total of 171 eligible long agonist ICSI cases were randomly allocated on day of ER into group A (86) starting LS as daily IM 100 mg P4 on day of ER and group B (85) starting P4-LS on day of ET. Difficult ET was defined as blood on ET catheter and/or sounding or dilating the cervix. Primary outcome was the overall ratio of difficult ET and ratios on day 3 and 5 ET. Secondary outcome was the ongoing pregnancy rate (OPR) and implantation rate (IR). The results are presented as % for groups A and B respectively: overall difficult ET (44.1, 24.7) (p = 0.009); day 3 difficult ET (23.2, 24.4) (p = 0.45); day 5 difficult ET (62.7, 25.6) (p = 0.001); overall OPR (38.3, 44.7) (p = 0.43); day 3 ET OPR (41.8, 33.3) (p = 0.51); day 5 ET OPR (34.8, 57.5) (p = 0.048); overall IR (20.0, 22.5) (p = 0.62); day 3 ET IR (17.8, 13.4) (p = 0.44); day 5 ET IR (22, 34.1) (p = 0.09). In conclusion, starting P4 luteal support on egg retrieval day is associated with significantly higher ratio of difficult embryo transfer and lower ongoing pregnancy rate and tendency to lower IR in day 5 ET, so starting P4-LS on day of ET is recommended.

Impact of anxiety levels on difficulty of intrauterine insemination and treatment outcomes

AIM

The objective of this study was to determine the effect of anxiety on intrauterine insemination (IUI) results in couples with unexplained infertility. Second, the relationship between difficulty level of IUI procedure and anxiety were investigated.

METHODS

A total of 100 women undergoing first IUI treatment were enrolled into this prospective cross-sectional study. Participants were asked to complete the Beck Anxiety Inventory (BAI) before the IUI procedure and classified into two groups according to the anxiety score (minimal anxiety; BAI score <8, n = 73 and mild-to-moderate anxiety; BAI score ≥8, n = 27). Cervical condition was evaluated with speculum and presence of congenital anomalies, extensive leucorrhea or polypoid lesions were classified as unfavorable cervix. All of the patients were evaluated for difficulty of IUI and asked to state the severity of their pain with a visual analog scale after the procedure. Clinical pregnancy rates were also analyzed.

RESULTS

There was no statistically significant difference between the groups in terms of pregnancy rates (12.3% vs 14.8%, P = 0.743). visual analog scale score was significantly higher in mild-to-moderate anxiety group (P = 0.002). Anxiety levels were higher in patients with difficult IUI (10.5 vs 4.3, P < 0.001). In multivariate analysis, higher BAI scores (odds ratio: 1.1, 95% confidence interval: 1.0-1.2, P = 0.01) and unfavorable cervical condition (odds ratio: 3.6, 95% confidence interval: 1.2-10.7, P = 0.01) emerged as independent predictors for difficulty of IUI.

CONCLUSION

Evaluation of anxiety before IUI might help to predict difficulty of IUI and related pain. Although anxiety increases the difficulty of IUI, it does not affect pregnancy outcomes of the treatment.

Pregnancy rates from natural and artificial cycles of women submitted to frozen embryo transfers: a metanalysis

Objective:

To compare pregnancy rates from natural and artificial cycles of women submitted to frozen embryo transfers.

Methods:

A systematic review was performed by PubMed search using the following algorithm: (endometrial [All Fields] AND preparation [All Fields]) AND (("freezing"[MeSH Terms] OR "freezing"[All Fields] OR "frozen"[All Fields]) AND thawed [All Fields]) and (natural cycles) AND (artificial cycle). Inclusion criteria: prospective and retrospective cohort studies. Exclusion criteria: use of hCG in the natural cycle, oocyte donors, and use of disused freezing techniques. Data were analyzed with the SPSS v.23 software and with a significance level of 5%. The meta-analysis was performed with RevMan 5.3 software. I² was calculated.

Results:

709 papers were retrieved. Five studies fulfilled the inclusion and exclusion criteria. From these studies, we analyzed 8,968 natural or artificial cycles. A contingency table compared the results of the natural and artificial cycles and the number of clinical pregnancies obtained in each selected paper. The I² test resulted in high statistical heterogeneity (I²=77%). Studies by Morozov et al. (2007) and Zheng et al. (2015) obtained statistically significant results (p<0.03 and p<0.001): Morozov et al. (2007) found a higher pregnancy rate within natural cycles, and Zheng et al. (2015) found more positive outcomes when analyzing artificial cycles. The remaining selected studies did not show any statistical significance.

Conclusion

There is insufficient scientific evidence to state that the artificial cycle yields better pregnancy rates than the natural cycle in women submitted to frozen embryo transfer. Limitations of this study include a small number of papers and heterogeneity among the studies.

Subendometrial resistence and pulsatility index assessment of endometrial receptivity in assisted reproductive technology cycles

OBJECTIVE

To evaluate Subendometrial and Uterine artery resistance and pulsatility index continuous analysis as a predictor of Endometrial receptivity in Assisted Reproductive Technology (ART) Cycles.

DESIGN

Serial 2D transvaginal coloured power doppler ultrasound performed in women on ART cycle to evaluate a pattern that better predicts implantation rates. One hundred sixty-nine subjects on a prospective case control study were assessed. Uterine artery and Subendometrial resistance and pulsatility index was performed to all subjects at baseline (prior to ovarian controlled stimulation), at day 6, 8 and 10 of controlled ovarian stimulation, at trigger day and at embryo transfer day. Also the ratio of fluxometric parameters between Subendometrial blood flow and uterine artery was measured.

RESULTS

No statistical difference was noted between two groups in terms of demographics and ART procedures and scores. Uterine artery resistance and pulsatility index showed statistical difference between the two groups (implantation versus non-implantation group). Also statistical significance was obtained between two groups in terms of Subendometrial vascularization. Ratio between Subendometrial and Uterine artery showed lower values of fluxometric parameters in all range for the Subendometrial territory.

CONCLUSIONS

Serial Subendometrial and Uterine artery fluxometry may be a useful tool for clinicians in predicting endometrial receptivity enhancing elective embryo transfers in the same ART cycle.

Estimation of embryo transfer media viscosity and consideration of its effect on media and uterine fluid interactions

RESEARCH QUESTION

What are the viscosities of media used for human embryo transfer and what is the possible effect of viscosity as it relates to interactions between transfer media and uterine fluid.

DESIGN

Chamber slide filling times, in seconds, were used to calculate viscosity for each commercial and in-house modified medium, with 12 or 24 replicates per medium under standard operating procedure temperature and gas equilibration conditions used for embryo transfer. Means, standard deviations and coefficients of variation were calculated, and each viscosity was estimated using a regression equation; viscosities for each medium were presented for comparative purposes.

RESULTS

Complete culture media (G1-Plus, G2-Plus, G-TL, 1-Step, Global Total, Global Total HEPES, and Sperm Wash Medium) had viscosity estimates of 1.65 cP, 1.77 cP, 1.68 cP, 1.29cP, 1.18 cP, 1.15 cP, and 1.20 cP, respectively. Complete transfer media (EmbryoGlue, UTM), had viscosity estimates of 3.59 cP and 1.28 cP, respectively. Global HEPES medium with 10%, 20%, 30%, and 50% synthetic serum substitute (SSS) volume per volume had viscosity estimates 1.16 cP, 1.23 cP, 1.25 cP, and 1.34 cP, respectively. For reference, water had a viscosity estimate of 1.06 cP.

CONCLUSIONS

A relatively narrow distribution of viscosities was observed across several transfer media despite the various commercial or in-house modifications. These data demonstrate the vast difference between viscosities of embryo transfer media and the assumed viscosity of uterine fluid (1000 cP). Contemporary embryo transfer media may be well-suited for IVF, but evaluation of all variables, e.g. media viscosity in the context of embryo transfer, adds to the knowledge base that should be available to practitioners.

Ultrasound guidance versus the blind method for intrauterine catheter insemination: A randomized controlled trial

Objective

The primary objective of this study was to compare clinical pregnancy rates in intrauterine insemination (IUI) treatment cycles with transabdominal ultrasound guidance during intrauterine catheter insemination (US-IUI) versus the “blind method” IUI without ultrasound guidance (BM-IUI). The secondary objective was to compare whether US-IUI had better patient tolerability and whether US-IUI made the insemination procedure easier for the clinician to perform compared to BM-IUI.

Methods

This was a randomized controlled trial done at the Reproductive Medicine Unit of General Hospital Kuala Lumpur, Malaysia. We included women aged between 25 and 40 years who underwent an IUI treatment cycle with follicle-stimulating hormone injections for controlled ovarian stimulation.

Results

A total of 130 patients were recruited for our study. The US-IUI group had 70 patients and the BM-IUI group had 60 patients. The clinical pregnancy rate was 10% in both groups (p> 0.995) and there were no significant difference between the groups for patient tolerability assessed by scores on a pain visual analog scale (p= 0.175) or level of difficulty for the clinician (p> 0.995). The multivariate analysis further showed no significant increase in the clinical pregnancy rate (adjusted odds ratio, 1.07; 95% confidence interval, 0.85–1.34; p= 0.558) in the US-IUI group compared to the BM-IUI group even after adjusting for potential covariates.

Conclusion

The conventional blind method for intrauterine catheter insemination is recommended for patients undergoing IUI treatment. The use of ultrasound during the insemination procedure increased the need for trained personnel to perform ultrasonography and increased the cost, but added no extra benefits for patients or clinicians.

Endometrial scratching prior to IVF; does it help and for whom? A systematic review and meta-analysis

STUDY QUESTION

What is the effect of endometrial scratching in patients with or without prior failed ART cycles on live birth (LBR) and clinical pregnancy rates (CPR)?

SUMMARY ANSWER

It remains unclear if endometrial scratching improves the chance of pregnancy and, if so, for whom.

WHAT IS KNOWN ALREADY

Endometrial scratching is hypothesized to improve embryo implantation in ART. Multiple studies have been published, but it remains unclear if endometrial scratching actually improves pregnancy rates and, if so, for which patients.

STUDY DESIGN, SIZE, DURATION

For this review, a systematic search for published articles on endometrial scratching and ART was performed on 12 February 2018, in Pubmed, Embase and the Cochrane Library.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Randomized controlled trials (RCTs) that evaluated endometrial scratching in the cycle prior to the stimulation cycle and reported CPR or LBR were included. RCTs investigating the effect of scratching during the stimulation cycle, or prior to cryo-thaw cycles were excluded. Studies were assessed using the Cochrane Risk of Bias tool. The effect of scratching was assessed for three different patient groups: patients with no prior IVF/ICSI treatment (Group 0), patients with one failed full IVF/ICSI cycle, including cryo-thaw cycles (Group 1) and patients with two or more failed full IVF/ICSI cycles (Group 2). A meta-analysis was performed when statistical heterogeneity was low; otherwise, a descriptive analysis was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Fourteen RCTs involving 2537 participants were included. Most RCTs contained a high or unclear risk of bias on one or more items. Substantial clinical and statistical heterogeneity was present; therefore meta-analysis for LBR and CPR could only be performed on Group 1. For this group, no differences between scratch and control were found for both LBR (risk ratio (RR) 1.01 [95%CI 0.68–1.51]) and CPR (RR 1.04 [95%CI 0.74–1.45]). For Groups 0 and 2, pooled analysis could not be performed, and for both groups the results of the individual RCTs were negative, neutral and positive. Miscarriage and multiple pregnancy rates were evaluated for the three groups (0, 1 and 2) together. Both outcomes were not significantly different between scratch and control (miscarriage rate RR 0.82 [95%CI 0.57–1.17] and multiple pregnancy rate RR 1.06 [95%CI 0.84–1.35]). Subgroup analysis, excluding trials with a risk of unintentional endometrial injury in the control group, was performed for Group 0 and 2 for LBR and CPR, and for the overall groups for miscarriage rate and multiple pregnancy rate. This reduced the heterogeneity and allowed for pooled analysis in these subgroups. Results of pooled analysis for the subgroups of Group 0 and 2 showed no significant difference for LBR, but CPR was significantly improved after endometrial scratching (Group 0 RR 1.28 [95%CI 1.02–1.62] and Group 2 RR 2.03 [95%CI 1.20–3.43]). Subgroup analysis of the overall groups showed no significant difference for miscarriage and multiple pregnancy rate.

LIMITATIONS REASONS FOR CAUTION

The main limitations were that many RCTs had a high or unclear risk of bias on one or several items, clinical heterogeneity was still present despite categorizing into three populations, and that not all RCTs could be included in the analyses because separate data for our three groups could not be provided.

WIDER IMPLICATIONS OF THE FINDINGS

It remains unclear if endometrial scratching improves the chance of pregnancy for women undergoing ART and, if so, for whom. This means endometrial scratching should not be offered in daily practice until results from large and well-designed RCTs and an individual patient data analysis become available.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was sought for the study. The Department of Reproductive Medicine and Gynaecology funds of the University Medical Center of Utrecht were used to support the authors throughout the study period and preparation of the manuscript. None of the authors has a conflict of interest to declare.

REGISTRATION NUMBER

Not applicable.

Overcoming the Challenging Cervix: Identification and Techniques to Access the Uterine Cavity

Importance

Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.

Objective

The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.

Evidence Acquisition

Computerized searches of MEDLINE and PubMed were conducted using the key words "cervix", "cervical stenosis," "embryo transfer," "hysteroscopy complications," "misoprostol," and "ultrasound." References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.

Results

Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.

Conclusions and Relevance

Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.

Accuracy and efficacy of embryo transfer based on the previous measurement of cervical length and total uterine length

PURPOSE

Aim of the study was to examine the accuracy of embryo transfer based on the previous measurement of cervical length and total uterine length.

METHODS

The study has taken place in an academic-assisted reproduction clinic. 248 patients with infertility requiring IVF/ICSI treatment have been included. All patients underwent IVF/ICSI cycles with antagonist protocol and were treated with controlled ovarian stimulation using recombinant FSH (100-400 IU/day). On the day of oocyte retrieval, all patients were given vaginally natural micronized progesterone in a dose of 200 mg/tds. All patients had transvaginal ultrasound measurement of cervical length and endometrial cavity length prior to embryo transfer and measurement of embryo distance (intrauterine air bubbles) from fundal surface of uterine cavity and internal cervical os immediately after embryo transfer. Embryo transfer was performed on days 2-3. Primary outcome was to estimate the accuracy of embryo transfer based on the measurement of the embryo distance from middle of uterine cavity after embryo transfer and secondary outcome was to assess the effect of embryo distance from uterine fundus and internal cervical os to clinical pregnancy rate.

RESULTS

The clinical pregnancy rate was 42.7%. The mean embryo distance from the middle of endometrial cavity was 0.48 ± 0.02 cm, the mean embryo distance from the uterine fundus was 0.88 ± 0.32 cm, and from the internal cervical os was 1.67 ± 0.45 cm. Multiple regression analysis showed that the embryo distance from middle of cavity was related to endometrial cavity length and to the embryo distance from the fundus and it was not related to Cx length, total uterine length, embryo distance from internal Cx os, and embryo transfer length.

CONCLUSIONS

Embryo transfer with the previous measurement of total uterine length and estimation of embryo transfer length can be performed with very good accuracy by a single operator.

Numerical simulation of embryo transfer: how the viscosity of transferred medium affects the transport of embryos

Background

Embryo transfer (ET) is a key step of assisted reproductive procedures, where the transferred medium containing the embryos is injected into the uterine cavity through a transcervical catheter and blended with intrauterine fluid in the uterine cavity. This procedure determines the delivery sites of embryos in the uterine cavity and has crucial impact on the implantation. Due to practical restrictions and ethical issues, it is often difficult to perform an in vivo study in humans to examine factors that affect the motions and delivery of embryos during ET. Alternatively, mathematical modeling is a powerful tool to that end.

Results

A computational model is developed to simulate the intrauterine mixing flow and track the embryo motions. Two important factors affecting the intrauterine flow are studied via this model: the viscosity of the transferred medium and the injection speed. Numerical results show that the dispersion pattern and the final delivery sites of the embryos are significantly influenced by the viscosity of the transferred medium. Specially, increasing the transferred medium viscosity close to that of the uterine fluid can enhance the probability that the embryos are delivered close to the fundus and keep them from being dragged backward to the cervix during catheter withdrawal. In addition, a slow injection speed can lower the driving force on the embryo during ET, which can prevent the embryo from being injured.

Conclusions

Based on our study, the practice of using a transferred medium with similar viscosity to that of the uterine fluid and a slow injection speed is recommended for real embryo transfer procedures in clinic.

Difficult Embryo Transfer: A Systematic Review

We performed a systematic review on the clinical epidemiology and outcome of difficult embryo transfers (ETs) in infertility patients who present with difficult ET. We searched PubMed, ScienceDirect, and Elsevier journals from 1980 to June 2017. We aimed to determine the most successful method resulting in highest pregnancy rates (PRs) in patients with difficult ET. We identified 50 articles, in which 36 were reviewed and 15 were included. Analysis of the data collected showed that the majority of the difficult ETs were caused by cervical stenosis and the most common treatment was cervical dilation. We concluded that cervical dilation was effective at managing difficult ET. Hegar dilators used a minimum of 3 weeks before ET showed to have higher PR.

Water-extracted tubers of Cyperus rotundus L. enhance endometrial receptivity through leukemia inhibitory factor-mediated expression of integrin αVβ3 and αVβ5

ETHNOPHARMACOLOGICAL RELEVANCE

Cyperus rotundus L. (CR) has been traditionally used as an herbal medicine in Asian countries to treat diverse gynecological disorders. However, the potential therapeutic effect of CR on endometrial receptivity for successful embryo implantation to treat female infertility has not been fully studied.

AIM OF STUDY

The aim of this study was to evaluate the effect of water-extracted CR on endometrial receptivity by investigating the expression of leukemia inhibitory factor (LIF) and integrins, cell adhesion, and embryo implantation using mifepristone (RU486; RU)-induced implantation failure model.

MATERIALS AND METHODS

The water extract of CR was prepared and fingerprinted using high-performance liquid chromatography (HPLC). For the expression and regulation of LIF, reverse transcription polymerase chain reaction (RT-PCR) and western blotting were performed in CR-stimulated Ishikawa cells. To evaluate LIF-mediated integrin expression, knockdown of LIF by shRNA was performed in Ishikawa cells. The effect of CR on endometrial receptivity was determined by an in vitro adhesion assay between JAr cells and CR-induced Ishikawa cells. In vivo, C57BL/6 female mice (n = 7 per group) orally received CR (31.68mg/kg/day), a similar dose as used clinically. Seven days after CR treatment, all female mice were caged with male mice until pregnancy was verified. On day 4 of pregnancy, RU (4mg/kg) was injected subcutaneously to induce embryo implantation failure.

RESULT

CR increased the expression of LIF through the phosphatidylinositol-3-kinase/ protein kinase B (PI-3K/AKT) signaling pathway in Ishikawa cells. In addition, CR enhanced adhesion of JAr cells onto Ishikawa cells by inducing the expression of LIF-dependent integrins αVβ3 and αVβ5. Furthermore, CR improved the number of implantation sites in pregnant mice despite RU injection.

CONCLUSION

CR increased the expression of LIF-mediated integrins αVβ3 and αVβ5 on the surface of endometrial cells, which is associated with adhesion of trophoblastic cells to endometrial cells for blastocyst implantation. Our findings provide evidence that CR has therapeutic potential against poor endometrial receptivity.

Transvaginal ultrasound-guided embryo transfer in IVF

OBJECTIVES

To determine whether transvaginal ultrasound-guided embryo transfer is a technique that can be used routinely, whether it improves IVF outcomes and whether it makes difficult transfers easier and more successful.

MATERIAL AND METHOD

Non-randomized retrospective study conducted between 2012 and 2016 in the fertility center of the Diaconesses-Croix St-Simon hospital group. The outcomes of 3910 transfers, performed by 5 senior operators, under transabdominal ultrasound guidance are compared with those of 800 transfers, performed by 1 senior operator under transvaginal ultrasound guidance. The criteria studied are the feasibility of the technique and the percentage of pregnancies per transfer in the two populations described, as well as in the difficult and very difficult transfer populations.

RESULTS

All the transfers were feasible under transvaginal ultrasound guidance without the use of forceps or additional instruments. The percentage of pregnancies per transfer is significantly increased, when the transfer is performed under transvaginal ultrasound guidance compared with that performed under transabdominal ultrasound guidance, in the general population (38%, n=800 vs 30%, n=3910; P 0.0004) and in the reference population characterized by age <38 years and >6 oocytes collected per puncture (45%, n=490 vs 36%, n=1968; P 0.002). The percentage of pregnancies per transfer (P/T) is not significantly different in the populations of easy transfers (n 695, 38% P/T), difficult transfers (n 58, 46% P/T; P=ns) and very difficult transfers (n 47, 34% P/T; P=ns).

CONCLUSIONS

Embryo transfer is a key stage in IVF, in which the quality of performance determines the outcome. In this study, transvaginal ultrasound guidance of the transfer, which is the reference procedure in gynaecological imaging, significantly increases the percentage of pregnancies per transfer, both in the general population and in the reference population, compared with transfers performed under transabdominal ultrasound guidance. Transvaginal ultrasound facilitates the performance of difficult transfers and in particular achieves outcomes in these situations that are not significantly different from those of easy transfers. Visual monitoring of transcervical passage, which is rendered more precise and less traumatic and precision of embryo deposition are the factors that probably account for the improvement in outcomes.

Assessment of the uterus with three-dimensional ultrasound in women undergoing ART

BACKGROUND

A detailed assessment of the uterus forms a pivotal part of the ART treatment process. The emergence of three-dimensional ultrasound (3D US) has provided clinicians with a highly powerful tool in this respect. Assessments with 3D US range from the reconstruction of anatomical planes elusive to conventional US, to the objective measurement of anatomical volumes and vascularization parameters. However, despite the ever increasing number of publications emerging in the literature, the question of which aspects of 3D US are of most clinical value remains a topic of debate.

OBJECTIVE AND RATIONALE

The objective of this review is to dissect which aspects of the 3D US assessment of the uterus are supported by a strong level of evidence to date, and should therefore be incorporated into current routine clinical practice.

SEARCH METHODS

We conducted a systematic search of the PubMed database up to May 2016, using a combination of text words and Medical Subject Headings (MeSH) pertaining to the 3D US assessment of the uterus. All articles published in the English language were screened to ascertain relevance to women of reproductive age; further citations were retrieved through manual reference list searching.

OUTCOMES

A multitude of predominantly observational studies were identified, which concerned a vast variety of 3D US uterine assessments. All articles unequivocally praised the non-invasive, cost-effective, highly acceptable and objective nature of 3D US. Studies regarding the value of assessing the endometrial volume and vascularization prior to embryo transfer appeared conflicting and inconsistent. Studies regarding the imaging of uterine pathology and identification of intratubal and intrauterine devices consistently reported high rates of diagnostic accuracy. A recent RCT did not show an improvement in clinical outcomes when comparing 3D versus 2D US during embryo transfer. However, preliminary studies suggested that 3D US is superior in determining the site of implantation, particularly in ambiguous cases such as interstitial and angular pregnancies. Finally, pilot studies have suggested that the further integration of 3D and possibly 4D US with surgical interventions of the uterus may be a promising prospect.

WIDER IMPLICATIONS

3D US may prove to be an invaluable tool in the assessment of the uterus within the context of ART. Currently, the aim should be to highlight the aspects of 3D US that are most evidence-based and valuable for patients, and to incorporate these into routine clinical practice.

Ultrasound in Infertility Treatments

Ultrasound (US) is very useful in diagnosing causes of infertility. Pelvic masses, mullerian anomalies, ovarian reserve, and tubal patency can all be assessed using ultrasonographic techniques. US has also proven to be a very useful aid in managing infertility treatments. In this chapter, we review the uses of US in monitoring follicular development, assessing the endometrium during treatment, and as an aid to embryo transfer during in vitro fertilization.

How often does the embryo implant at the location to which it was transferred?

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.

Hysteroscopic-guided local endometrial injury does not improve natural cycle pregnancy rate in women with unexplained infertility: Randomized controlled trial

AIM

To evaluate the efficacy of a hysteroscopic site-specific local endometrial injury (LEI) in a group of women with unexplained infertility (UI) undergoing expectant management with no fertility treatment versus no intervention.

METHODS

This open-label, randomized controlled trial (RCT) was conducted between June 2013 and July 2015. Hysteroscopic site-specific LEI was determined by patient identification number, and 120 women were included. Eligible participants were randomly assigned to receive either a single, site-specific LEI guided by hysteroscopy (study group, n = 60) or no intervention (control group, n = 60). Natural cycle folliculometry and timed intercourse were carried out for all participants for 3 months. Successful clinical pregnancy confirmed on ultrasound was the primary outcome measure, and first trimester miscarriage rate was the secondary outcome.

RESULTS

After identification, baseline clinical demographics were similar in the two groups. No statistically significant differences were noted in cumulative pregnancy rates in women with LEI compared with those without (16.7% and 11.7 %, respectively; OR, 2.83; 95%CI: 1.07-7.48; P = 0.4). One first trimester miscarriage was reported in the control group (14.3%).

CONCLUSION

Local endometrial injury for natural cycle conception in women with UI is not justified. Further RCT are warranted to prove or disprove this.

Ectopic pregnancy risk factors for ART patients undergoing the GnRH antagonist protocol: a retrospective study

BACKGROUND

In-vitro fertilization is a known risk factor for ectopic pregnancies. We sought to establish the risk factors for ectopic pregnancy in GnRH antagonist cycles examining patient and stimulation parameters with an emphasis on ovulation trigger.

METHODS

We conducted a retrospective, cohort study of 343 patients undergoing 380 assisted reproductive technology (ART) cycles with the GnRH antagonist protocol and achieving a clinical pregnancy from November 2010 through December 2015.

RESULTS

Significant risk factors for ectopic pregnancy in the univariate analysis included prior Cesarean section (CS), endometriosis, mechanical factor infertility, longer stimulation, elevated estradiol and progesterone levels, GnRH agonist trigger, higher number of oocytes aspirated, and insemination technique. Independent risk factors for ectopic pregnancy in the multivariate analysis included GnRH agonist trigger, higher number of oocytes aspirated, insemination technique, and prior Cesarean section.

CONCLUSION

Excessive ovarian response, IVF (as opposed to ICSI), prior Cesarean section and GnRH agonist trigger were found to be independent risk factors for ectopic pregnancy. Caution should be exercised before incorporating the GnRH agonist trigger for indications other than preventing OHSS. When excessive ovarian response leads to utilization of GnRH agonist trigger, strategies for preventing ectopic pregnancy, such as a freeze all policy or blastocyst transfer, should be considered. Further studies should elucidate whether adjusting the luteal support can reduce the ectopic pregnancy risk.

The effect of embryo catheter loading technique on the live birth rate

Objective

Embryo loading (EL) is a major step in embryo transfer (ET) and affect on the success of in vitro fertilization (IVF). This study aimed to compare the effect of two different EL techniques on the rates of pregnancy and delivery in IVF/ET cycles.

Methods

207 fresh ET and 194 Frozen-thawed ET (FET) cycles were included in this retrospective study. Two groups (A and B) were defined based on the EL technique used. In group A, the entire catheter was flushed with Ham's F-10 medium. The embryos were then drawn into the catheter using one air bracket. In group B, 70 µL of air was aspirated into the syringe and the catheter was flushed using Ham's F10 medium. The medium, air, embryos, air, and finally another layer of medium were then sequentially drawn into the catheter. The main outcome measures were the pregnancy and delivery rates.

Results

The groups did not differ with respect to the etiology of infertility, the source of spermatozoa, the quality of the embryos, the type of EL catheter, and the ease of transfer. The pregnancy rate was similar between two groups. In fresh ET cycles, a higher delivery rate was observed in group B than it group A (78.1% vs. 60%, p=0.1). In FET cycles, the rate of delivery was significantly higher in group B than in group A to a nonsignificant extent (88.9% vs. 58.8%, p=0.06).

Conclusion

EL techniques did not have a significant impact on the delivery rate in either fresh or FET cycles.

Impact of blastocyst biopsy and comprehensive chromosome screening technology on preimplantation genetic screening: a systematic review of randomized controlled trials

Embryonic aneuploidy is highly prevalent in IVF cycles and contributes to decreased implantation rates, IVF cycle failure and early pregnancy loss. Preimplantation genetic screening (PGS) selects the most competent (euploid) embryos for transfer, and has been proposed to improve IVF outcomes. Use of PGS with fluorescence-in-situ hybridization technology after day 3 embryo biopsy (PGS-v1) significantly lowers live birth rates and is not recommended for use. Comprehensive chromosome screening technology, which assesses the whole chromosome complement, can be achieved using different genetic platforms. Whether PGS using comprehensive chromosome screening after blastocyst biopsy (PGS-v2) improves IVF outcomes remains to be determined. A systematic review of randomized controlled trials was conducted on PGS-v2. Three trials met full inclusion criteria, comparing PGS-v2 and routine IVF care. PGS-v2 is associated with higher clinical implantation rates, and higher ongoing pregnancy rates when the same number of embryos is transferred in both PGS and control groups. Additionally, PGS-v2 improves embryo selection in eSET practice, maintaining the same ongoing pregnancy rates between PGS and control groups, while sharply decreasing multiple pregnancy rates. These results stem from good-prognosis patients undergoing IVF. Whether these findings can be extrapolated to poor-prognosis patients with decreased ovarian reserve remains to be determined.

Reporting of embryo transfer methods in IVF research: a cross-sectional study

The reporting of embryo transfer methods in IVF research was assessed through a cross-sectional analysis of randomized controlled trials (RCTs) published between 2010 and 2011. A systematic search identified 325 abstracts; 122 RCTs were included in the study. Embryo transfer methods were described in 42 out of 122 articles (34%). Catheters (32/42 [76%]) or ultrasound guidance (31/42 [74%]) were most frequently mentioned. Performer 'blinding' (12%) or technique standardization (7%) were seldom reported. The description of embryo transfer methods was significantly more common in trials published by journals with lower impact factor (less than 3, 39.6%; 3 or greater, 21.5%; P = 0.037). Embryo transfer methods were reported more often in trials with pregnancy as the main end-point (33% versus 16%) or with positive outcomes (37.8% versus 25.0%), albeit not significantly. Multivariate logistic regression confirmed that RCTs published in higher impact factor journals are less likely to describe embryo transfer methods (OR 0.371; 95% CI 0.143 to 0.964). Registered trials, trials conducted in an academic setting, multi-centric studies or full-length articles were not positively associated with embryo transfer methods reporting rate. Recent reports of randomized IVF trials rarely describe embryo transfer methods. The under-reporting of research methods might compromise reproducibility and suitability for meta-analysis.