A meta-analysis of ultrasound-guided versus clinical touch embryo transfer

Clinical aspects of oocyte retrieval and embryo transfer. Tips and tricks for the novice and experts

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.

Efficacy of a modified transvaginal ultrasound-guided fresh embryo transfer procedure

OBJECTIVE

To present a modified transvaginal ultrasound (TVUS) guided embryo transfer (ET) procedure and analyze its efficacy in comparison with conventional transabdominal ultrasound (TAUS) guided ET in an unselected population of Brazilian women.

METHODS

This retrospective observational case-control study involved 447 fresh ET cycles, 221 guided by TVUS (Group 1), conducted between June 2016 and February 2019, and 226 by TAUS (Group 2), conducted between July 2012 and December 2015. Pregnancy rate was the main endpoint. Groups were compared using the Z test at a level of significance of 95% (p≤0.05).

RESULTS

Patient age ranged from 21 and 48 years; mean age was 37.7 years in Group 1 and 38 years in Group 2. Overall, patients that underwent TVUS-guided fresh ET demonstrated significantly higher pregnancy rates than their counterparts that underwent TAUS-guided fresh ET (p=0.0107). TVUS-guided fresh ET also yielded significantly higher pregnancy rates in the subgroups of women aged 36-39 years (p=0.0037) and ≥ 40 years (p=0.0025). However, no significant pregnancy rate difference was observed in women aged ≤ 35 years (p=0.0905).

CONCLUSIONS

The results suggested that TVUS-guided fresh ET was at least as effective as TAUS-guided fresh ET in the studied sample. Pending further prospective studies to better ascertain the effect of TVUS-guided ET, the technique presented deserves consideration since it can offer better visualization, more comfort to patients, and requires only one operator, without negatively affecting pregnancy results.

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.

PATIENTS

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 MEASURES

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.

RESULTS

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.

CONCLUSIONS

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.

The position of the euploid blastocyst in the uterine cavity influences implantation

RESEARCH QUESTION

Does the position of the euploid blastocyst in the uterine cavity upon transfer, measured as distance in millimetres (mm) from the fundus (DFF) to the air bubble, influence implantation potential?

DESIGN

A total of 507 single/double euploid frozen embryo transfer (FET) cycles at blastocyst stage were included retrospectively between March 2017 and November 2018 at a single centre. The patients were on average 33.3 years old. The FET were performed in natural cycles (n = 151) or hormone replacement therapy cycles (n = 356).

RESULTS

Of the 507 transfers, 370 (73.0%) resulted in a pregnancy, defined as human chorionic gonadotrophin concentration over 15 mIU/ml, and 341 (67.3%) in a clinical pregnancy, with an implantation rate of 62.0% and ongoing pregnancy rate of 59.6% (302/507). When comparing the number of embryos transferred, the pregnancy rate, clinical pregnancy rate and ongoing pregnancy rate were significantly higher after double-embryo transfer (DET) (P = 0.002: P < 0.001 and P = 0.002). The quality of the blastocyst in the single-embryo transfer group had a positive effect on the pregnancy rate (A versus B, P = 0.016; A versus C, P = 0.003) and clinical pregnancy rate (A versus C, P = 0.013). After performing a multivariate logistic regression analysis to consider the effect of all explanatory variables, a negative effect between DFF and pregnancy (P = 0.001), clinical pregnancy (P = 0.001) and ongoing pregnancy (P = 0.030) was found. When all variables remained constant, an increase of 1 mm of DFF changed the odds of pregnancy by 0.882, of clinical pregnancy by 0.891 and of ongoing pregnancy by 0.925. No significant effect of DFF was found on the miscarriage outcome (P = 0.089).

CONCLUSIONS

The depth of blastocyst replacement inside the uterine cavity may influence the pregnancy, clinical pregnancy and ongoing pregnancy rates and should be considered as an important factor to improve the success of IVF cycles.

Intrauterine insemination performance characteristics and post-processing total motile sperm count in relation to live birth for couples with unexplained infertility in a randomised, multicentre clinical trial

STUDY QUESTION

Are intrauterine insemination (IUI) performance characteristics and post-processing total motile sperm count (TMC) related to live birth rate in couples with unexplained infertility?

SUMMARY ANSWER

Patient discomfort with IUI and lower inseminate TMC were associated with a reduced live birth rate, while time from hCG injection to IUI, sperm preparation method and ultrasound guidance for IUI were not associated with live birth success.

WHAT IS ALREADY KNOWN

We previously determined that some baseline characteristics of couples with unexplained infertility, including female age, duration of infertility, history of prior loss and income, were related to live birth rate across a course of ovarian stimulation and IUI treatment. However, the relationship between treatment outcomes and per-cycle characteristics, including ultrasound guidance for IUI, timing of IUI relative to hCG injection, difficult or painful IUI and inseminate TMC, are controversial, and most prior investigations have not evaluated live birth outcome.

STUDY DESIGN, SIZE, DURATION

This was a secondary analyses of 2462 cycles from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. This prospective, randomised, multicentre clinical trial determined live birth rates following IUI after ovarian stimulation with clomiphene citrate, letrozole or gonadotropins in 854 couples with unexplained infertility. It was conducted between 2011 and 2014, and couples could undergo up to four consecutive treatment cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

AMIGOS was an NIH-sponsored Reproductive Medicine Network trial conducted at 12 clinical sites. Participants were women with unexplained infertility who were between 18 and 40 years of age. Cluster-weighted generalised estimating equations (GEE), which account for informative clustering of multiple IUI treatment cycles within the same patient, were used to determine associations between IUI performance characteristics, including inseminate TMC, and live birth rate. Efficiency curves were also generated to examine the relationship between inseminate TMC and live birth rate.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjustment for treatment group and baseline factors previously associated with live birth across a course of OS-IUI treatment, patient discomfort during the IUI procedure was associated with a reduction in live birth rate (aRR 0.40 (0.16-0.96)). Time from hCG trigger injection to IUI was not significantly associated with outcome. Higher TMC was associated with greater live birth rate (TMC 15.1-20.0 million (14.8%) compared to ≤5 million (5.5%)) (aRR 2.09 (1.31-3.33)). However, live births did occur with TMC ≤ 1 million (5.1%).

LIMITATIONS, REASONS FOR CAUTION

This investigation is a secondary analysis, and AMIGOS was not designed to address the present question. Since timed intercourse was allowed as part of the AMIGOS trial, we cannot rule out the possibility that any given pregnancy resulted from intercourse rather than IUI.

WIDER IMPLICATIONS OF THE FINDINGS

Most factors associated with the performance of IUI were not significantly related to obtaining live birth. Our findings suggest that higher TMC inseminated leads to an increase in live birth rate up to TMC ~20 million. However, there may be no reasonable threshold below which live birth is not possible with IUI.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10 HD055925. This research was made possible by funding by the American Recovery and Reinvestment Act. Dr Hansen reports grants from NIH/NICHD and Yale University during the conduct of the study, grants from Roche Diagnostics and grants from Ferring International Pharmascience Center US outside the submitted work. Dr Peck reports support from Ferring Pharmaceuticals outside the submitted work. Dr Coward has nothing to disclose. Dr Wild reports grants from NICHD during the conduct of the study. Dr Trussell has nothing to disclose. Dr Krawetz reports grants from NICHD during the conduct of the study, grants from Merck and support from Taylor and Frances and from Springer, outside the submitted work. Dr Diamond reports grants from NIH/NICHD, Yale University, during the conduct of the study and support from Advanced Reproductive Care AbbVie, Bayer and ObsEva, outside the submitted work. Dr Legro reports support from Bayer, Kindex, Odega, Millendo and AbbVie and grants and support from Ferring, outside the submitted work. Dr Coutifaris reports grants from NICHD/NIH and personal fees from American Society for Reproductive Medicine, outside the submitted work. Dr Alvero has nothing to disclose. Dr Robinson reports grants from NIH during the conduct of the study. Dr Casson has nothing to disclose. Dr Christman reports grants from NICHD during the conduct of the study. Dr Santoro reports grants from NIH during the conduct of the study. Dr Zhang reports grants from NIH during the conduct of the study and support from Shangdong University outside the submitted work.

TRIAL REGISTRATION NUMBER

n/a.

Correlation of Site of Embryo Transfer with IVF Outcome: Analysis of 743 Cycles from a Single Center

OBJECTIVE

To investigate the influence of site of embryo transfer (ET) on reproductive outcome.

MATERIALS AND METHODS

A retrospective analysis of 743 ultrasound-guided ET in fresh in vitro fertilization (IVF) cycles from a single center over a period of 4 years was conducted. The distance between the fundal endometrial surface and the air bubble was measured, and accordingly, patients were divided into four groups (≤10 mm; >10 and ≤15 mm; >15 and 20 mm; >20 and <25 mm).

SETTING

Tertiary Assisted Reproductive Technology (ART) center.

PATIENTS

All patients enrolled in the IVF program undergoing ET.

INTERVENTIONS

Controlled ovarian hyperstimulation (OS), IVF, and ET.

MAIN OUTCOME MEASURES

Cleavage rate and clinical pregnancy rate.

RESULTS

Clinical pregnancy rate was significantly more in groups 2 and 3 compared to the other groups. Logistic regression analysis showed that one unit increase in embryos transfer will enhance the pregnancy outcome about 3.7 (adjusted odds ratio) times with 95% confidence limits 2.6 to 5.4. Similarly, pregnancy outcome will be 3.1 (95% confidence limits: 1.5-6.4) times higher for distance group >15 and <20 mm compared to less than 10-mm distance group. Ectopic pregnancy rates were similar in all the four groups.

CONCLUSION

The present study demonstrates that site of ET has significant difference on reproductive outcome.

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.

Does the Presence of Blood in the Catheter or the Degree of Difficulty of Embryo Transfer Affect Live Birth?

The technique used for embryo transfer (ET) can affect implantation. Prior research that evaluated the effect of postprocedural blood of the transfer catheter tip have yielded mixed results, and it is unclear whether this is actually a marker of difficulty of the transfer. Our objective was to estimate the effect of blood at the time of ET and the difficulty of ET on live birth rates (LBR). This retrospective cohort study utilized generalized estimating equations (GEEs) with nesting for repeated cycles for all analyses. Univariate modeling was performed and a final multivariate (adjusted) GEE model accounted for all significant confounders. Embryo transfers were subjectively graded (easy, medium, or hard) by a physician at the time of transfer. The presence of blood at ET was associated with more difficult ETs, retained embryos, and presence of mucous in the catheter. In the univariate analysis, ET with blood was not associated with live birth, while the degree of difficulty for ET had a negative impact on LBR. In the final multivariate GEE model, which accounts for repeated cycles from a patient, the only factors associated with an increased LBR were the degree of difficulty of the ET, female age, and blastocyst transfer. After controlling for confounding variables, the presence of blood in the transfer catheter was not associated with the likelihood of pregnancy and thus was not an independent predictor of cycle outcome. This indicates that the difficulty of the transfer itself was a strong negative predictor of pregnancy.

Large randomized trial comparing transabdominal ultrasound-guided embryo transfer with a technique based on uterine length measurement before embryo transfer

OBJECTIVE

To compare in a randomized, non-inferiority trial the embryo transfer (ET) technique based on uterine length measurement before transfer (ULMbET) with transabdominal ultrasound-guided embryo transfer (TA-UGET) in a large population of patients undergoing in-vitro fertilization (IVF).

METHODS

Patients undergoing IVF with ET with cleaving fresh embryos were randomized to receive ULMbET or TA-UGET. The transfer of one to three embryos on day 2-3 of culture was performed using a soft catheter either under transabdominal ultrasound guidance (TA-UGET group) or after measurement of the uterine cavity by transvaginal ultrasound and calculation of the discharge site (ULMbET group). The primary outcome measures were clinical pregnancy rate, ongoing pregnancy rate and implantation rate, and secondary outcomes included patient discomfort during ET.

RESULTS

A total of 1648 patients undergoing IVF were randomized to receive ULMbET (n = 828) or TA-UGET (n = 820) and were included in the analysis. Comparable clinical pregnancy rate (38.2% vs 38.9%), implantation rate (24.8% vs 25.2%) and ongoing pregnancy rate (33.1% vs 34.8%) were observed in ULMbET and TA-UGET groups. The discomfort intensity score and the proportion of patients with moderate-to-severe discomfort during ET were significantly higher in the TA-UGET group (2.6 vs 1.5 visual analog scale points and 19.8% vs 1.2%; P = 0.045 and P = 0.003, respectively).

CONCLUSION

The ULMbET technique leads to IVF results comparable to those obtained with UGET, but is better tolerated than is TA-UGET and is technically easier to perform for a single operator. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

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.

Absolute position versus relative position in embryo transfer: a randomized controlled trial

BACKGROUND

Meta-analysis revealed that embryo placement 20 mm from the fundal endometrial surface resulted in higher pregnancy rate, ongoing pregnancy rate, and live birth rate compared with placement 10 mm from the fundal endometrial surface. Pregnancy and implantation rates according to relative position were higher when the catheter tip was positioned close to the middle of the endometrial cavity. The aim of the current study is to evaluate differences in implantation and pregnancy rates if the site of embryo transfer is 2 cm distance from the fundal endometrium (DFE) compared to the midpoint of the endometrial cavity length (ECL).

METHODS

Patients were randomized to one of two groups: in group A (n = 98, 98 IVF-ET cycles), the embryo transfer catheter tip was positioned 2 cm DFE, while that in group B (n = 97, 97 IVF-ET cycles) was positioned at the midpoint of the ECL. We compared pregnancy outcomes of implantation rate, chemical pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, ectopic pregnancy rate, and miscarriage rate in the two groups.

RESULTS

Analysis of implantation rate (19.5 ± 27.7 vs. 21.7 ± 32.6; p = 0.6), chemical pregnancy rate (51 % vs. 50.5 %; p = 0.94), clinical pregnancy rate (35.7 % vs. 38.1 %; p = 0.73), ongoing pregnancy rate (31.6 % vs. 30.9 %; p = 0.92), ectopic pregnancy rate (8.6 % vs. 2.7 %; p = 0.35), and miscarriage rate (11.4 % vs. 16.2 %; 0.74) revealed comparable results for both groups.

CONCLUSIONS

Implantation and pregnancy rates were not influenced by the site of the ET catheter tip being 2 cm DFE compared to at the midpoint of the ECL.

ISRCTN

ISRCTN15972342.

Predictive value of the time interval between embryo loading and transfer for IVF/ICSI success: a prospective cohort study

BACKGROUND

The influence of embryo loading time (ELT) and the time interval between embryo loading and embryo transfer (TIEL-ET) on the success of IVF/ICSI is unknown.

METHODS

In a prospective cohort study, we aimed to ascertain the influence of ELT and TIEL-ET on ongoing pregnancy rate (OPR) and life birth rate (LBR). Data from 603 consecutive embryo transfers between January 2008 and December 2013 were collected. A complete data set including the outcomes of interest OPR and LBR was available for 410 women. The primary outcome was IVF/ICSI success, defined as OPR and LBR.

RESULTS

We used univariate and multivariate logistic regression for analysis. In a multivariate analysis, age (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.89-0.99), catheter type (OR 0.45; 95% CI 0.24-0.84), and uterine length (OR 1.03; 95% CI 1.01-1.06), but not ELT and TIELT-ET were independently associated with OPR. Regarding LBR, age (OR 0.93; 95% CI 0.88-0.98), catheter type (OR 0.41; 95% CI 0.22-0.79), and uterine length (OR 1.03; 95% CI 1.01-1.06), but not ELT and TIELT-ET were independent predictors.

CONCLUSION

We conclude that speed of embryo transfer is not critical for the success of IVF/ICSI. However, care should be taken to choose catheter types proven to be associated with a high success rate.

Outcome Analysis of Day-3 Frozen Embryo Transfer v/s Fresh Embryo Transfer in Infertility: A Prospective Therapeutic Study in Indian Scenario

INTRODUCTION

Advanced fertilization techniques like frozen embryo transfer (FET) and assisted reproductive technology have become popular and commonly used methods to treat patients suffering from infertility. Incidences of infertility are on a rise due to increased representation of females in the work place, delay in marriages, stress, and ignorance.

METHODS

We performed this prospective therapeutic study to compare FET and fresh embryo transfer in the treatment of infertility in terms of conception rate, patient acceptance, complications, and patient's compliance. A prospective screening therapeutic study on 108 patients, from September 2013 to September 2014 in Karnataka, India, randomized the patients into 2 groups (n = 54), Group-I treated with day-3 FET while Group-II was treated with fresh embryo transfer, after performing ICSI.

RESULTS

In 108 patients, 45 % patients were within 35 years of age, 35 % were in the age group 35-39. Significantly, 22 (40.75 %) patients treated with FET conceived (P = 0.022), whereas 16 (29.63 %) patients treated with fresh embryo transfer conceived (P = 0.59).

DISCUSSION

There is limited published literature from the subcontinent, comparing techniques like FET and embryo transfers in the treatment of infertility. Awareness and economic reforms must be formulated in India to facilitate individuals facing infertility problems to conceive.

CONCLUSION

FET has better and significant conception rates compared to fresh embryo transfers. FET shares an advantage of providing good quality embryos for future and subsequent implantations in cases of failure. Patient counseling and motivation play a pivotal role in the success of therapeutic procedure.

Embryo transfer by reproductive endocrinology fellows vs attending physicians: are live birth rates comparable?

OBJECTIVE

To compare live birth rates following ultrasound-guided embryo transfer (ET) by reproductive endocrinology and infertility fellows versus attending physicians.

STUDY DESIGN

Women who underwent their first day-3, fresh, nondonor ET between Oct. 1, 2005, and April 1, 2011, at our academic center were included in this retrospective cohort study. Embryos were designated high quality if they had 8 cells, less than 10% fragmentation, and no asymmetry. ET was performed with the afterload technique under ultrasound guidance. Categorical variables were evaluated with the χ(2) test and continuous variables with the Student t test. Logistic regression was performed to assess the relationship between ET physician and live birth rate while adjusting for potential confounders.

RESULTS

Seven hundred sixty women underwent ET by an attending physician, and 104 by a fellow. Baseline characteristics were similar between the groups. The live birth rate was 31% following ET by an attending physician, compared with 34% following ET by a fellow (P = .65). Logistic regression adjusting for potential confounders demonstrated no significant association between ET physician and live birth rate.

CONCLUSION

This retrospective study demonstrated no significant difference in live birth rates following ultrasound-guided ET by fellows vs attending physicians at our institution. These data suggest that academic practices using the afterload method and ultrasound guidance can train fellows to perform ET without compromising success rates.

Embryo catheter loading and embryo culture techniques: results of a worldwide Web-based survey

PURPOSE

To identify trends in embryo catheter loading and embryo culture techniques performed worldwide.

METHODS

A retrospective evaluation using the results of a web-based survey, (IVF Worldwide ( www.IVF-worldwide.com ), was performed.

RESULTS

Responses from 265 centers in 71 countries were obtained. Most centers (97 %) preferred a catheter with its orifice on top, with only 3 % preferring a catheter with the orifice on its side; 41 % preferred a catheter marked for clear ultrasound view. The most commonly-reported methods of embryo loading were medium-air-embryo-air-medium (42 %), medium in catheter with embryo at end (20 %) and medium-air-embryo (15 %). In 68 % of centers the final volume of the catheter was up to 0.3 ml, with only 19 % using 0.3-0.5 ml and 1 % using 0.5-0.7 ml. Using reduced oxygen concentrations for embryo culture was divided between those who used it in combination with the two-gas system (34 %) and those who did not use it at all (39 %); 24 % reported using a three-gas system. Most clinics using reduced oxygen concentrations used it throughout the entire culture period. Half of centers (51 %) reported using reduced oxygen concentrations for the entire IVF population while 6 % reserved it only for blastocyst transfer. The use of sequential media was highly dominant with 40 % reporting its use.

Embryo transfer

Embryo transfer is a critical step in the overall success of in vitro fertilization (IVF). Despite its apparent simplicity, it is an integral part of the IVF cycle that can be difficult to teach and perform well. In this chapter we describe the procedure of embryo transfer and discuss various modifications that have been evaluated in an effort to improve the probability of embryo implantation including ultrasound guidance, catheter design, transfer technique, as well as enrichment of the embryo transfer media.

The Impact of the Depth of Embryo Replacement into the Uterine Cavity under Transabdominal Ultrasound Guidance on In Vitro Fertilization and Embryo Transfer Outcome

Aim: The aim of the present study was to determine the importance of the depth of embryo replacement into the uterine cavity (upper or lower half endometrial cavity) on the implantation clinical pregnancy rates.Material and Methods: In this prospective observational were included 160 patients underwent controlled ovarian hyperstimulation followed by IVF/ICSI and embryo transfer. On the day of embryo transfer under direct transabdominal ultrasound guidance, the transfer catheter was advanced to a defined distance from the uterine fundus, up to the point estimated for transfer: 10 ± 2.5 mm (Group A) and 15 ± 2.5 mm (Group B).Results: In total, 160 patients, aged 24-42 years were included in the study. Overall clinical pregnancy rate were 41.2%. Analysis of our results demonstrated that pregnancy rate is significantly influenced by transfer distance from the fundus where the  pregnancy rate decreases from 48.7% in group B to 34.5%  in group A (p<0.05). There was not significantly difference in abortion rate between the two groups.Conclusion: In conclusion, our results suggest that depth of embryo replacement inside the uterine cavity may influence the pregnancy rates and should be considered as an important factor to improve the success of IVF cycles.

Assessment of pregnancy-associated, within-woman change in uterine length

OBJECTIVE

To evaluate how absolute uterine length changes as a result of pregnancy.

METHODS

Longitudinal repeated-measures study of all women presenting to a university-affiliated clinic for uterine sounding prior to in vitro fertilization (IVF) who went on to deliver at term and return for repeat measurement from 2002 to 2012. Change in uterine length was assessed by the Wilcoxon signed-rank test.

RESULTS

Among 495 women, mean pregnancy-associated change in uterine length was 0.0 cm (SD ± 0.7, p = 0.84), with 31% of women experiencing no change and 75% of women experiencing a change ≤0.5 cm. Mean uterine lengths at pre-cycle and repeat measurement were 7.2 cm (SD ± 0.7) and 7.2 cm (SD ± 0.7) with medians of 7.0 cm (IQR 7.0-7.5) and 7.0 cm (IQR 6.8-7.8), respectively. Change in uterine length did not vary by gestational number or within time interval between measurements (all p > 0.5).

CONCLUSIONS

There was no difference in uterine length before and after term pregnancy. The finding of minimal variation in uterine length both across and within women suggests uterine length may be relatively stable such that patients undergoing IVF after term IVF pregnancy may not require repeat measurement. Future studies might assess pregnancy-associated sonographic changes in uterine volume and the relationship between uterine length and IVF outcomes.

Intraoperative imaging

Intraoperative image is a rapidly expanding field encompassing many applications that use a multitude of technologies. Some of the these applications have been in use for many years and are firmly embedded in, and indispensable to, clinical practice (e.g. the use of X-ray to locate foreign bodies during surgery or oocyte retrieval under ultrasound guidance. In others, the application may have been in use in one discipline but not yet fully explored in another. Examples include the use of intraoperative ultrasound with or without contrast enhancement for the detection of hepatic metastases not identified preoperatively, and the effect of such additional information on the ultimate operative procedure. Intraoperative identification of sentinel lymph nodes has been explored in many specialties to a varying extent, with the aim of fine tuning and avoiding unnecessary surgery. In both these instances, we do not know the long-term effect of these interventions on patient survival or quality of life. In this chapter, we will explore the available evidence on these applications and current advances in the new technology in general, with a specific focus on gynaecology.

[Professional Practice Evaluation: How to improve quality management in procreation centers?]

OBJECTIVES

The Professional Practice Evaluation (PPE) is at the heart of quality management in procreation centers. Hereby, we report 3 years of EPP in Cytogenetics and Reproduction laboratory in Amiens University Hospital.

PATIENTS AND METHODS

This PPE is based upon prospective analysis of in vitro fertilization techniques regarding two major parameters: clinically in improving embryo transfer and biologically by determining fecundation levels. Clinical pregnancies in "Top Quality" trial is chosen as a major indicator of our results.

RESULTS

Per transfer, there is an increase of 8% for clinical pregnancies and 31% in "Top quality" trials.

DISCUSSION AND CONCLUSION

The improvement in our results allowed us to propose, in favourable conditions, single embryo transfer.

[Quality of transfer. Biologist and clinician's point of view]

Embryonic transfer is one of the briefest procedures in the long-lasting chain of events occurring during an infertility treatment. Embryo transfer is, however, one of the most crucial steps in assisted reproductive technologies. The realization of this ultimate gesture involves the control of numerous parameters that exert an impact on its success. These various influential factors engage the multidisciplinary team: biologist, clinician... to permanently search for ways to optimize embryo transfer outcome.

Firm versus soft embryo transfer catheters under ultrasound guidance: Does catheter choice really influence the pregnancy rates?

In contrast to the previously published evidence, under ultrasound guidance, individual catheter choice does not statistically significantly affect the clinical pregnancy rate in a modern clinical IVF practice. This may be as a result of decreasing the incidence of difficult transfers and endometrial injury with ET under ultrasound guidance.

What is the best site for embryo deposition? A systematic review and meta-analysis using direct and adjusted indirect comparisons

The site of embryo replacement has been postulated as being important to the success of IVF/ICSI. In order to determine the best site for embryo deposition during embryo transfer, a meta-analysis of randomized trials comparing different uterine deposition sites was undertaken. Electronic (e.g. PubMed, EMBASE, Cochrane Library, LILACS) and hand searches were performed to locate trials. Outcomes measures were the live-birth (LBR), ongoing pregnancy (OPR), and clinical pregnancy rates (CPR). Assessments of the endometrial cavity length (ECL) and the distance from the fundus to the tip of the catheter (DTC) were utilized. Six studies were identified, of which three were excluded. Meta-analysis was conducted with the Mantel-Haenszel method, utilizing the fixed-effects model. The LBR and OPR showed an increasing trend when transfers were performed to the lower half of the uterine cavity. For the DTC, all rates were significantly higher for the approximately 20 mm versus approximately 10 mm distance from the uterine fundus, supporting the results of the ECL analysis. The results of this systematic review show that there is limited evidence of the superiority of lower cavity transfers (e.g. approximately 20 mm) compared with the traditional high cavity (e.g. approximately 10 mm) transfers. More well-designed and powered randomized trials are needed to confirm this conclusion.

Uterine Position Change Between Mock and Real Embryo Transfers

OBJECTIVE

This study was designed to assess the change in uterine position between mock and real embryo transfers.

MATERIALS AND METHODS

A total of 386 embryo transfer cycles were reviewed, and the uterine position was recorded at the time of mock embryo transfer and then again at the time of real embryo transfer.

RESULTS

Of 254 patients with an anteverted uterus at mock transfer, only 3 (1.2%) were found to have a retroverted uterus at actual embryo transfer. Of 132 patients with a retroverted uterus at mock transfer, 24 (18%) had an anteverted uterus at actual embryo transfer (p < 0.0001).

CONCLUSION

Routine ultrasound-guided embryo transfer is suggested when a retroverted uterus is found at mock embryo transfer, as there is a significant chance that the uterine position will change.

Bioengineering Studies of the Embryo Transfer Procedure

Embryo transfer (ET) is the final manual intervention in extracorporeal fertilization in which an embryo is transferred into the uterus by a transcervical catheter. The low rates of embryo implantation within the uterus are attributed, among other factors, to the ET technique, which depends on a multitude of anatomical, physiological, and mechanical aspects. We developed computational and experimental models to simulate ET to examine the contribution of mechanical features to the success of this procedure. The experimental model allowed laboratory simulations of the dispersion of the catheter load as a result of different injection speeds into a tilted uterine model. The mathematical model analyzed potential trajectories of the transferred embryos resulting from the interaction between the injection velocity and the intrauterine flows caused by uterine peristalsis. The simulations revealed the important contribution of mechanical parameters, such as the position of the uterus and the presence of air in the catheter load. The latter was found to increase the potential for the embryo to be near the fundal area during the time limit for implantation. Based on the results of our simulations, we recommended performing ET in a patient-specific position in which the fundus will be the highest point above the horizon and that the load be delivered slowly, that is, not less than 10 s. We also recommended placing the tip of the catheter at the mid cavity to avoid ectopic pregnancy.

Ultrasound-guided embryo transfer does not offer any benefit in clinical outcome: a randomized controlled trial

BACKGROUND

Ultrasound-guided embryo transfer (ET) is widely suggested as a standard clinical practice that improves overall embryo implantation and pregnancy rates. Various studies of this issue suffer from methodological pitfalls, so that a randomized controlled trial, which overcomes these problems, might be valuable.

METHODS

Three hundred women aged <40, who underwent fresh ET, were included in this randomized, double-blind controlled trial. The K-J-SPPE echo tip soft catheter was used for the ultrasound-guided ET and the traditional K-Soft catheter for ETs not using ultrasound. One experienced operator performed all ETs. The primary study outcome was overall pregnancy rate (defined as the number of positive hCG results per transfer).

RESULTS

No significant differences between groups were found regarding baseline patient and embryological characteristics, except for male factor and unexplained infertility (higher in the blind and ultrasound-guided ET group, respectively, P < 0.05). Overall pregnancy rates were 53.3 and 51.3% in the ultrasound-guided and blind ET group, respectively. Two ectopic pregnancies were reported in each group. Difficulty in cervical negotiation did not differ between the two groups.

CONCLUSIONS

In patients undergoing ET by an experienced operator, ultrasound guidance did not provide any benefit in terms of overall clinical pregnancy and embryo implantation rates.

Use of phenazopyridine for reducing discomfort during embryo transfer

OBJECTIVE

The embryo transfer is a critical part of in vitro fertilization. When performed under abdominal ultrasound guidance, the embryo transfer procedure requires a full bladder. Patients often state that the discomfort of the distended bladder causes more pain than the actual transfer procedure. Phenazopyridine HCl is a bladder analgesic. The objective of this study was to determine if a single dose of phenazopyridine prior to embryo transfer reduces patient discomfort during that procedure.

DESIGN

Prospective randomized double-blinded clinical trial.

SETTING

University-based Reproductive Medicine practice.

PATIENT(S)

Eighty-five reproductive age infertile women undergoing in vitro fertilization.

INTERVENTION(S)

Phenazopyridine (200 mg) or placebo taken 1 hour prior to embryo transfer utilizing transabdominal sonography.

MAIN OUTCOME MEASURE(S)

Pain as assessed by visual analogue pain scale and physician and nurse assessment of patient discomfort.

RESULT(S)

Study groups were similar in their demographic background. Mean pain score as assessed by a visual analogue pain scale during the procedure was 2.95 +/- 2.4 in the placebo group, and 3.03 +/- 2.6 in the active medication group (NS). There were also no significant differences in the observations of pain assessments.

CONCLUSION(S)

Phenazopyridine used in a single dose prior to embryo transfer does not alleviate patient discomfort.

The pre-cycle blind mock embryo transfer is an inaccurate predictor of anticipated embryo transfer depth

PURPOSE

To assess if the uterine cavity depth measured by a blind pre-cycle mock transfer changes after gonadotropin stimulation.

METHODS

This is a retrospective cohort study at an academic IVF program involving 128 infertility patients. The main outcome measures were uterine cavity depth measured at the blind pre-stimulation mock transfer and the ultrasound-guided embryo transfer.

RESULTS

A >or= 1 cm increase in uterine cavity depth was found in 57.9% of the patients. The mean pre-cycle blind mock transfer uterine depth significantly differed from the mean uterine depth measured at embryo transfer. Based on the mock transfer, the anticipated embryo transfer depth was significantly less than the actual ultrasound-guided embryo transfer depth.

CONCLUSION

Uterine depth significantly differed between the blind pre-cycle mock transfer measurement and the ultrasound-guided embryo transfer measurement. The mock transfer may predict a difficult embryo transfer but it is an inaccurate predictor of the final embryo transfer depth.