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McQueen DB, Borazjani A, Yeh C, Dong S, Milad MP, Feinberg EC. The use of an embryo transfer simulator to compare transfer techniques and pregnancy outcomes among physicians. F S Rep 2024; 5:183-188. [PMID: 38983724 PMCID: PMC11228883 DOI: 10.1016/j.xfre.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/11/2024] [Accepted: 04/23/2024] [Indexed: 07/11/2024] Open
Abstract
Objective To evaluate the association between embryo transfer techniques and pregnancy outcomes. Design This is a prospective observational study with a retrospective cohort. Setting University Clinic. Patients Patients underwent embryo transfers between 2015 and 2020. Intervention/Exposure Fourteen physicians performed 25 mock embryo transfers on the embryo transfer simulator and completed a questionnaire assessing preferred embryo transfer techniques. Quantitative performance metrics on the embryo transfer simulator were measured. Individual physician embryo transfer success rates were retrospectively collected from all fresh and cryopreserved embryo transfers between January 1, 2015, and January 1, 2020. Associations between embryo transfer techniques (preferred technique and simulator performance metrics) and each physician's historical patient pregnancy outcomes were assessed. Main Outcome Measures Associations between embryo transfer techniques and live births were assessed. Results There were significant differences in embryo transfer techniques between physicians, including touches to the fundus, distance to the fundus, duration of embryo transfer, duration of the complete procedure, time spent navigating the cervical canal, velocity of embryo expulsion, time waited after embryo expulsion, and total score on the embryo transfer simulator. After controlling for confounders and multiple transfers per physician, the duration of embryo transfer was significantly associated with live birth, with longer durations associated with decreased live birth rates. Shorter placement distance to the fundus and higher velocity of embryo expulsion were both significantly associated with higher rates of ectopic pregnancy. Conclusions This study revealed significant differences in transfer techniques among physicians. The use of the embryo transfer simulator for physicians in practice can elucidate differences and create opportunities for data-driven improvement in embryo transfer success rates.
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Affiliation(s)
- Dana B McQueen
- Reproductive Medicine Associates, IVI RMA Northern California, San Francisco, California
| | - Ali Borazjani
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Chen Yeh
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Siyuan Dong
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Magdy P Milad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Eve C Feinberg
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Cirillo F, Immediata V, Ronchetti C, Carletti T, Morenghi E, Albani E, Baggiani A, Levi-Setti PE. Steps forward in embryo transfer technique: a retrospective study comparing direct versus afterload catheters at different time frames. J Assist Reprod Genet 2023; 40:2895-2902. [PMID: 37819552 PMCID: PMC10656400 DOI: 10.1007/s10815-023-02957-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023] Open
Abstract
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.
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Affiliation(s)
- Federico Cirillo
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Valentina Immediata
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Camilla Ronchetti
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Teresa Carletti
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Emanuela Morenghi
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
- Biostatistics Unit, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
| | - Elena Albani
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
| | - Annamaria Baggiani
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital IRCCS, via Manzoni 57, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy.
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Oskowitz SP, Rwiyereka AK, Rurangwa T, Shepard DS, Rwamasirabo E, Isaacson KB, van der Poel S, Racowsky C. Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda. F S Rep 2023; 4:130-142. [PMID: 37398610 PMCID: PMC10310971 DOI: 10.1016/j.xfre.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objective To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country. Design Retrospective review of the clinical and laboratory components of patients undergoing in vitro fertilization (IVF) treatment in Rwanda from 2018 to 2020. Setting Academic tertiary referral hospital in Rwanda. Patients Patients seeking infertility services beyond the primary gynecological options. Interventions The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature. Main Outcome Measures Assessment of functional clinical and laboratory infertility services and costs. Results A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively. Conclusions Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.
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Affiliation(s)
- Selwyn P. Oskowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | - Angélique K. Rwiyereka
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Théogène Rurangwa
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics and Gynecology, Rwanda Military Hospital, Kigali, Rwanda
| | - Donald S. Shepard
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Schneider Institutes for Health Policy and Research, Institute for Global Health and Development, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts
| | - Emile Rwamasirabo
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Rwanda Accreditation Agency for Quality Healthcare (RAAQH), Kigali, Rwanda
| | - Keith B. Isaacson
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
| | | | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Rwanda Infertility Initiative (RII), Los Angeles, California
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
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Bourdon M, Ouazana M, Maignien C, Pocate Cheriet K, Patrat C, Marcellin L, Gonnot J, Cervantes C, Laviron E, Blanchet V, Chapron C, Santulli P. Embryo transfer learning using medical simulation tools: a comparison of two embryo transfer simulators. J Gynecol Obstet Hum Reprod 2023; 52:102542. [PMID: 36682581 DOI: 10.1016/j.jogoh.2023.102542] [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: 05/02/2022] [Revised: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Mathilde Bourdon
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Department 3I « Infection, Immunité et inflammation", Institut Cochin, INSERM U1016, France
| | - Marion Ouazana
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Chloe Maignien
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Khaled Pocate Cheriet
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of histology -embryology and reproductive biology, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Catherine Patrat
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of histology -embryology and reproductive biology, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Louis Marcellin
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Department 3I « Infection, Immunité et inflammation", Institut Cochin, INSERM U1016, France
| | - Juia Gonnot
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Celie Cervantes
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Emmanuelle Laviron
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Valerie Blanchet
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Charles Chapron
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Department 3I « Infection, Immunité et inflammation", Institut Cochin, INSERM U1016, France
| | - Pietro Santulli
- Université de Paris, Faculty of Medicine, Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Department 3I « Infection, Immunité et inflammation", Institut Cochin, INSERM U1016, France.
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Reindollar RH. The American Society for Reproductive Medicine Embryo Transfer Simulator Initiative has come full circle: an editorial. F S Rep 2023; 4:22-23. [PMID: 36959961 PMCID: PMC10028467 DOI: 10.1016/j.xfre.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Richard H Reindollar
- Emeritus Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Baker KM, Leung AQ, Shah JS, Korkidakis A, Sakkas D, Penzias A, Toth TL. Simulation-based training for embryo transfer for clinicians with differing levels of expertise: an application of the American Society for Reproductive Medicine Embryo Transfer Simulator. F S Rep 2023; 4:29-35. [PMID: 36959969 PMCID: PMC10028427 DOI: 10.1016/j.xfre.2022.08.003] [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: 01/14/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To compare the learning curve of clinicians with different levels of embryo transfer (ET) experience using the American Society for Reproductive Medicine (ASRM) Embryo Transfer Simulator. Design Prospective cohort study. Setting Single large university-affiliated in vitro fertilization center. Patients Participants with 3 levels of expertise with ET were recruited: "group 1" (Reproductive Endocrinology and Infertility attendings), "group 2" (Reproductive Endocrinology and Infertility nurses, advance practice providers, or medical assistants), and "group 3" (Obstetrics and Gynecology resident physicians). Interventions All participants completed ET simulation training using uterine cases A, B, and C (easiest to most difficult) of the ASRM ET Simulator. Participants completed each case 5 times for a total of 15 repetitions. Main Outcome Measures The primary outcome was ET simulation scores analyzed at each attempt for each uterine case, with a maximum score of 155. Secondary outcomes included self-assessed comfort levels before and after the completion of the simulation and total duration of ET. Comfort was assessed using a 5-point Likert scale. Results Twenty-seven participants with 3 different levels of expertise with ET were recruited from December 2020 to February 2021. For cases A and B, median total scores were not significantly different between groups 1 and 3 at first or last attempts. Group 2 did not perform as well as group 3 at the beginning of case A or group 1 at the end of case B. All groups demonstrated a decrease in total time from the first attempt to the last attempt for both cases. For case C, the "difficult" uterus, groups 2 and 3 exhibited the greatest improvement in total median score: from 0 to 75 from the first to last attempt. Group 1 scored equally well from first through last attempts. Although no one from group 2 or 3 achieved a passing score with the first attempt (80% of the max score), approximately 30% had passing scores at the last attempt. Groups 1 and 3 showed a significant decrease in total time across attempts for case C. Following simulation, 100% of groups 2 and 3 reported perceived improvement in their skills. Group 3 showed significant improvement in comfort scores with Likert scores of 1.71 ± 0.76 and 1.0 ± 0.0 for the "Easy" and "Difficult" cases, respectively, before simulation and 4.57 ± 0.53 and 2.4 ± 1.1 after simulation. Conclusions The ASRM ET Simulator was effective in improving both technical skill and comfort level, particularly for those with little to no ET experience and was most marked when training on a difficult clinical case.
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Affiliation(s)
- Katherine M. Baker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Reprint requests: Katherine M. Baker, M.D., Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Kirstein 3, Boston, Massachusetts 02215.
| | - Angela Q. Leung
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Boston IVF, Waltham, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Jaimin S. Shah
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Boston IVF, Waltham, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Ann Korkidakis
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Boston IVF, Waltham, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | | | - Alan Penzias
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Boston IVF, Waltham, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Thomas L. Toth
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Boston IVF, Waltham, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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Training for the future. Curr Opin Obstet Gynecol 2022; 34:172-178. [PMID: 35895957 DOI: 10.1097/gco.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the evolving field of Reproductive Endocrinology and Infertility (REI) and describe the current and future challenges REI fellowship programmes in the United States are facing. RECENT FINDINGS The field of REI continues to rapidly evolve largely due to the tremendous advances within the assisted reproductive technologies (ARTs). Alongside this evolution, there is a lessening emphasis on graduates being proficient in all aspects of REI. Ongoing revisions to the REI fellowship structure reflect these changes in technology and contemporary practice patterns. SUMMARY REI is a rapidly evolving field and fellowship training is continually adapting to meet the changing landscape of our field.
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Sallam HN, Gelbaya TA, Rosas IM, Anagnostopoulou C, Sallam N, Agarwal A. Clinical aspects of oocyte retrieval and embryo transfer. Tips and tricks for the novice and experts. Panminerva Med 2022; 64:185-199. [PMID: 35179015 DOI: 10.23736/s0031-0808.22.04679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oocyte retrieval (ovum pick-up) and embryo transfer (ET) are essential steps in IVF and ICSI and over the years, the two procedures were developed in order to improve the clinical outcome. Many suggestions were proposed and applied before, during and after oocyte retrieval such as timing of HCG trigger, pre-operative pelvic scan, vaginal cleansing, type of anesthesia, type and gauge of aspiration needles, aspiration pressure, follicle flushing, and the need for prophylactic antibiotics. Similarly, many steps were suggested and implemented before, during and after ET including patient's position, type of anesthesia/analgesia, dummy (mock) ET, ultrasound-guidance, HCG injection in the uterine cavity, use of relaxing agents, full bladder, removal of the cervical mucus, flushing the cervix with culture medium, type of ET catheter, embryo loading techniques, site of embryo deposition, the use of adherence compounds, as well as bed rest after ET. Complications were also reported with oocyte retrieval and ET. The aim of this review is to evaluate the current practice of these two procedures in the light of available evidence.
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Affiliation(s)
- Hassan N Sallam
- Department of Obsterics and Gynaecology, Alexandria University Faculty of Medicine, Alexandria, Egypt -
| | - Tarek A Gelbaya
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, UK
| | - Israel M Rosas
- Citmer Reproductive Medicine, IVF LAB, Mexico City, Mexico
| | | | - Nooman Sallam
- Department of Obstetrics and Gynaecology, Guy's and St Thomas' NHS Trust, London, UK
| | - Ashok Agarwal
- Andrology Center and American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Levi Setti PE, Cirillo F, Morenghi E, Immediata V, Caccavari V, Baggiani A, Albani E, Patrizio P. One step further: randomised single-centre trial comparing the direct and afterload techniques of embryo transfer. Hum Reprod 2021; 36:2484-2492. [PMID: 34323282 DOI: 10.1093/humrep/deab178] [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: 12/25/2020] [Revised: 06/18/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- P E Levi Setti
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, School of Medicine, New Haven, CT, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - F Cirillo
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - E Morenghi
- Biostatistics Unit, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - V Immediata
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - V Caccavari
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy.,Division of Assisted Reproduction, Department of Gynecology, Istituto Clinico Città Studi, Milano, Italy
| | - A Baggiani
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - E Albani
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - P Patrizio
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, School of Medicine, New Haven, CT, USA
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Zhang L, Portenier T, Goksel O. Learning ultrasound rendering from cross-sectional model slices for simulated training. Int J Comput Assist Radiol Surg 2021; 16:721-730. [PMID: 33834348 PMCID: PMC8134288 DOI: 10.1007/s11548-021-02349-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Given the high level of expertise required for navigation and interpretation of ultrasound images, computational simulations can facilitate the training of such skills in virtual reality. With ray-tracing based simulations, realistic ultrasound images can be generated. However, due to computational constraints for interactivity, image quality typically needs to be compromised. METHODS We propose herein to bypass any rendering and simulation process at interactive time, by conducting such simulations during a non-time-critical offline stage and then learning image translation from cross-sectional model slices to such simulated frames. We use a generative adversarial framework with a dedicated generator architecture and input feeding scheme, which both substantially improve image quality without increase in network parameters. Integral attenuation maps derived from cross-sectional model slices, texture-friendly strided convolutions, providing stochastic noise and input maps to intermediate layers in order to preserve locality are all shown herein to greatly facilitate such translation task. RESULTS Given several quality metrics, the proposed method with only tissue maps as input is shown to provide comparable or superior results to a state-of-the-art that uses additional images of low-quality ultrasound renderings. An extensive ablation study shows the need and benefits from the individual contributions utilized in this work, based on qualitative examples and quantitative ultrasound similarity metrics. To that end, a local histogram statistics based error metric is proposed and demonstrated for visualization of local dissimilarities between ultrasound images. CONCLUSION A deep-learning based direct transformation from interactive tissue slices to likeness of high quality renderings allow to obviate any complex rendering process in real-time, which could enable extremely realistic ultrasound simulations on consumer-hardware by moving the time-intensive processes to a one-time, offline, preprocessing data preparation stage that can be performed on dedicated high-end hardware.
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Affiliation(s)
- Lin Zhang
- Computer-assisted Applications in Medicine, ETH Zurich, Zürich, Switzerland.
| | - Tiziano Portenier
- Computer-assisted Applications in Medicine, ETH Zurich, Zürich, Switzerland
| | - Orcun Goksel
- Computer-assisted Applications in Medicine, ETH Zurich, Zürich, Switzerland
- Department of Information Technology, Uppsala University, Uppsala, Sweden
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