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Tyler B, Walford H, Tamblyn J, Keay SD, Mavrelos D, Yasmin E, Al Wattar BH. Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses. Hum Reprod Update 2022; 28:480-500. [PMID: 35325124 PMCID: PMC9631462 DOI: 10.1093/humupd/dmac009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Bede Tyler
- UCL Institute for Women's Health, University College London, London, UK
| | - Hugo Walford
- UCL Institute for Women's Health, University College London, London, UK
| | - Jennifer Tamblyn
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Stephen D Keay
- Centre for Reproductive Medicine, University Hospital of Coventry & Warwickshire, Coventry, UK
| | - Dimitrios Mavrelos
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Ephia Yasmin
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Bassel H Al Wattar
- Correspondence address. Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK, WC1E 6DB. E-mail:
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Harbhajan Singh JS, Ahmad MF, Abu MA, Omar MH, Abdul Karim AK. A fine tuning of embryo loading technique by eliminating the air bubble in the outer sheath of embryo catheter among women undergoing IVF treatment. Horm Mol Biol Clin Investig 2021; 42:389-393. [PMID: 34323055 DOI: 10.1515/hmbci-2021-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/26/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Jasdev Singh Harbhajan Singh
- Advanced Reproductive Centre (ARC), Hospital Canselor Tuanku Mukhriz (HCTM) UKM, Cheras, Kuala Lumpur, Malaysia.,Obstetrics & Gynaecology Department, Klang Hospital, Klang, Selangor, Malaysia
| | - Mohd Faizal Ahmad
- Obstetrics & Gynaecology Department, Faculty of Medicine, Kuala Lumpur Campus, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia.,Advanced Reproductive Centre (ARC), Hospital Canselor Tuanku Mukhriz (HCTM) UKM, Cheras, Kuala Lumpur, Malaysia
| | - Muhammad Azrai Abu
- Obstetrics & Gynaecology Department, Faculty of Medicine, Kuala Lumpur Campus, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia.,Advanced Reproductive Centre (ARC), Hospital Canselor Tuanku Mukhriz (HCTM) UKM, Cheras, Kuala Lumpur, Malaysia
| | - Mohd Hashim Omar
- Obstetrics & Gynaecology Department, Faculty of Medicine, Kuala Lumpur Campus, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia.,Advanced Reproductive Centre (ARC), Hospital Canselor Tuanku Mukhriz (HCTM) UKM, Cheras, Kuala Lumpur, Malaysia
| | - Abdul Kadir Abdul Karim
- Obstetrics & Gynaecology Department, Faculty of Medicine, Kuala Lumpur Campus, National University of Malaysia, Cheras, Kuala Lumpur, Malaysia.,Advanced Reproductive Centre (ARC), Hospital Canselor Tuanku Mukhriz (HCTM) UKM, Cheras, Kuala Lumpur, Malaysia
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Moini A, Zafarani F, Jahangiri N, Jahanian Sadatmahalleh SH, Sadeghi M, Chehrazi M, Ahmadi F. The Effect of Vaginal Sildenafil on The Outcome of Assisted Reproductive Technology Cycles in Patients with Repeated Implantation Failures: A Randomized Placebo-Controlled Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2019; 13:289-295. [PMID: 31710189 PMCID: PMC6875854 DOI: 10.22074/ijfs.2020.5681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 03/02/2019] [Indexed: 11/23/2022]
Abstract
Background The aim of this study was to investigate the effects of vaginal sildenafil on the outcome of patients with
at least two unsuccessful in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) attempts. Materials and Methods In this randomized placebo-controlled trial study, a total of 66 infertile women aged ≤38
years, with a history of normal ovarian reserve, two prior consecutive failed IVF/ICSI attempts, human chorionic
gonadotropin (hCG) day endometrial thickness <7 mm in all prior IVF/ICSI cycles, normal endometrial appear-
ance by either hysteroscopy, hysterosonography, or hysterosalpingography enrolled in this study. The conventional
gonadotropin-releasing hormone (GnRH) protocol was used for ovarian stimulation. The patients were randomly
divided into three groups: vaginal sildenafil (suppository-100 mg/daily), vaginal placebo/sildenafil (suppository-100
mg/daily), and vaginal placebo (suppository). Each patient underwent colour Doppler ultrasound on day 14 of their
previous cycle to investigate any abnormalities in the uterus and adnexa. Endometrial thickness, echo pattern, uterine
artery resistance, and pulsatility indices were recorded pre- and post-treatment. The primary outcome measures were
implantation, chemical and clinical pregnancy rates. For data analysis, SPSS version 20 software was used. In all tests,
the significance level was considered less than 0.05. Results There was no significant difference between three groups in endometrial thickness on the hCG injection day.
The chemical pregnancy in women who received sildenafil (alone or in combination with placebo) showed a two-fold
increase in comparison to the placebo group. This increase was clinically meaningful, but according to sample size,
it was statistically non-significant. The results of our study showed that the implantation was higher in women who
received placebo/sildenafil compared to the other groups. The abortion rate was not statistically significant among the
groups. Conclusion Vaginal sildenafil may conceivably improve chemical pregnancy rates in repeated IVF failure patients.
Further randomized clinical trials using oral or vaginal sildenafil with higher sample size are recommended (Registra-
tion number: NCT03192709).
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Affiliation(s)
- Ashraf Moini
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran.,Department of Obstetrics and Gynaecology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Zafarani
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Nadia Jahangiri
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | | | - Marya Sadeghi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Mohammad Chehrazi
- Department of Biostatistics and Epidemiology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Firoozeh Ahmadi
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran.Electronic Address:
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Madani T, Ahmadi F, Jahangiri N, Bahmanabadi A, Bagheri Lankarani N. Does low-dose aspirin improve pregnancy rate in women undergoing frozen-thawed embryo transfer cycle? A pilot double-blind, randomized placebo-controlled trial. J Obstet Gynaecol Res 2018; 45:156-163. [PMID: 30178577 DOI: 10.1111/jog.13802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/07/2018] [Indexed: 12/30/2022]
Abstract
AIM To evaluate the effect of adjuvant low-dose aspirin therapy on clinical pregnancy rate and uterine perfusion in women undergoing frozen-thawed embryo transfer (FET) cycles. METHODS This study was performed as a pilot randomized, double-blind placebo-controlled trial, from May 2012 to February 2015. Overall, 60 available eligible women who were candidates for FET were randomly assigned to two groups receiving either 100 mg oral aspirin (n =30) or placebo (n =30). The primary outcome measure was clinical pregnancy rate. Secondary outcome measures were pulsatility index (PI), resistance index (RI), implantation rate, live birth rate and miscarriage rate. RESULTS There was no significant difference in endometrial thickness, PI and RI. However, the study group had higher rates of clinical pregnancy, implantation, live birth (P = 0.042, P = 0.031 and P = 0.007, respectively) and lower rate of miscarriage (P = 0.020) as compared to the control group. Twin birth rate was comparable between the two groups. CONCLUSION Our pilot study demonstrated that administration of low-dose aspirin in FET cycles results in better pregnancy, implantation and live birth rates without changing the uterine hemodynamics or endometrial thickness. However, further randomized clinical studies in larger populations are needed to confirm these findings.
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Affiliation(s)
- Tahereh Madani
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Firoozeh Ahmadi
- Department of Reproductive Imaging, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Nadia Jahangiri
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Akram Bahmanabadi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Narges Bagheri Lankarani
- Department of Epidemiology and Reproductive Health, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
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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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Liu R, Li Y, Miao Y, Wei Y, Guan M, Zhou R, Li X. Intrauterine air impairs embryonic postimplantation development in mice. Eur J Obstet Gynecol Reprod Biol 2017; 219:20-27. [PMID: 29031908 DOI: 10.1016/j.ejogrb.2017.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 09/19/2017] [Accepted: 10/09/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although most embryologists load air bubbles into the catheter along with embryos during embryo transfer, the effects of these air bubbles on embryo transfer success rate are not clear. STUDY DESIGN Air bubbles were nonsurgically injected into unilateral uterine horns of mice to demonstrate the negative effects of intrauterine air bubbles on embryonic development. RESULTS Our data showed that when air bubbles are nonsurgically injected into unilateral uterine horns of pregnant 4days mice the litter size is significantly decreased. Four days after the introduction of air, abnormal decidua and dead conceptuses were detected in the uterine horns receiving the air bubbles. In addition, intrauterine air also significantly impaired murine embryo transfer success rates, and induced an increase in endometrial capillary permeability and decidualization in mice on day 4 of pseudopregnancy. These results strongly indicated that the air bubbles loaded into embryo transfer catheters to bracket the embryo-containing medium may have negative effect on embryonic implantation and development. CONCLUSIONS Intrauterine air impaired murine embryonic postimplantation development, and this provided some clues for improving embryo transfer techniques in human.
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Affiliation(s)
- Ruonan Liu
- College of Animal Science and Technology, Hebei Agricultural University, Baoding, Hebei, 071000, China
| | - Yimeng Li
- College of Basic Medical Science, Hebei Medical University, Shijiazhuang, Hebei, 050000, China
| | - Yanping Miao
- College of Animal Science and Technology, Hebei Agricultural University, Baoding, Hebei, 071000, China
| | - Yanhui Wei
- College of Animal Science and Technology, Hebei Agricultural University, Baoding, Hebei, 071000, China
| | - Mo Guan
- MRC Harwell Institute, Harwell Campus, Mary Lyon Centre, Oxfordshire, OX11 0RD, UK
| | - Rongyan Zhou
- College of Animal Science and Technology, Hebei Agricultural University, Baoding, Hebei, 071000, China.
| | - Xiangyun Li
- College of Animal Science and Technology, Hebei Agricultural University, Baoding, Hebei, 071000, China.
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Sigalos G, Triantafyllidou O, Vlahos N. How do laboratory embryo transfer techniques affect IVF outcomes? A review of current literature. HUM FERTIL 2016; 20:3-13. [PMID: 27844488 DOI: 10.1080/14647273.2016.1255357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Over the last few years, many studies have focused on embryo selection methods, whereas little attention has been given to the standardization of the procedure of embryo transfer. In this review, several parameters of the embryo transfer procedure are examined, such as the: (i) culture medium volume and loading technique; (ii) syringe and catheters used for embryo transfer; (iii) viscosity and composition of the embryo transfer medium; (iv) environment of embryo culture; (v) timing of embryo transfer; (vi) and standardization of the embryo transfer techniques. The aim of this manuscript is to review these factors and compare the existing embryo transfer techniques and highlight the need for better embryo transfer standardization.
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Affiliation(s)
- George Sigalos
- a 2nd Department of Obstetrics and Gynaecology , Aretaieion Hospital University of Athens , Athens, Greece.,b Reproductive Medicine Unit , "Lito" Maternity Hospital , Athens , Greece
| | | | - Nikos Vlahos
- a 2nd Department of Obstetrics and Gynaecology , Aretaieion Hospital University of Athens , Athens, Greece
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Schoolcraft WB. Importance of embryo transfer technique in maximizing assisted reproductive outcomes. Fertil Steril 2016; 105:855-60. [DOI: 10.1016/j.fertnstert.2016.02.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 02/08/2016] [Accepted: 02/12/2016] [Indexed: 11/26/2022]
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Mahajan N, Gupta I. Use of Versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilization-embryo transfer outcome: A case series. J Hum Reprod Sci 2011; 4:12-6. [PMID: 21772733 PMCID: PMC3136061 DOI: 10.4103/0974-1208.82353] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 10/06/2010] [Accepted: 12/29/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Smooth atraumatic embryo transfer is paramount for the success of in-vitro fertilization (IVF). In difficult cases, cervical canal manipulation may be required. AIM To see if surgical correction of the cervical canal or cervical canal refashioning could improve ease of embryo transfer. SETTING Private infertility and IVF hospital. DESIGN Prospective study. MATERIALS AND METHODS PATIENTS 11 women with failed 1-3 IVF cycles with history of extremely difficult embryo transfers (ETs) despite undergoing cervical dilatation in the cycle prior to IVF. INTERVENTIONS Operative hysteroscopy using Versapoint for refashioning of the cervical canal. MAIN OUTCOME MEASURES Ease of ET in the subsequent IVF cycle. Secondary outcome measure was to assess reproductive outcome. RESULTS Easy and atraumatic ET in the IVF cycle after procedure in 100% patients. PR was 46.5%. CONCLUSIONS Use of Versapoint for refashioning the cervical canal can improve the quality of ET and PR.
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Affiliation(s)
- Nalini Mahajan
- Department of Infertility and IVF, Mother and Child Hospital, New Delhi, India
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Improving of pregnancy rate by modifying embryo transfer technique. Fertil Steril 2010; 94:e68. [PMID: 20691436 DOI: 10.1016/j.fertnstert.2010.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 06/28/2010] [Indexed: 11/22/2022]
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