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Rosas IM, Anagnostopoulou C, Singh N, Gugnani N, Singh K, Desai D, Darbandi M, Manoharan M, Darbandi S, Chockalingam A, Leonardi Diaz SI, Gupta S, Kuroda S, Finelli R, Sallam HN, Wirka KA, Boitrelle F, Agarwal A. Optimizing embryological aspects of oocyte retrieval, oocyte denudation, and embryo loading for transfer: a state of the art review. Panminerva Med 2022; 64:156-170. [PMID: 35146991 DOI: 10.23736/s0031-0808.22.04675-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oocyte retrieval, oocyte denudation, and embryo transfer are crucial processes during assisted reproduction (ART). Air quality in the ART laboratory, temperature, pH of the media used and the time interval between oocyte retrieval and insemination are all critical factors. Anesthesia is required for oocyte retrieval, however evidence regarding the potential impact of different methods (general anesthesia, conscious sedation, and local anesthesia) on the clinical outcomes is unclear. The optimal timing of oocyte denudation following retrieval has not been established. Regarding the mechanical denudation process, there is a lack of evidence to demonstrate the safest minimum inner diameter of denuding pipettes used to complete the removal of granulosa cells surrounding the oocytes. During embryo transfer, many clinics worldwide flush the catheter before embryo loading, in an attempt to potentially rinse off any toxic agents; however, there is insufficient evidence to show that flushing the embryo transfer catheter before loading increases the success of ART outcome. Considering the serious gaps in knowledge in ART practice, the aim of this review is to provide an updated overview of the current knowledge regarding the various steps and techniques involved in oocyte retrieval, oocyte denudation, and embryo loading for transfer.
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Affiliation(s)
- Israel M Rosas
- Citmer Reproductive Medicine, IVF LAB, Mexico City, Mexico
| | | | | | - Nivita Gugnani
- BabySoon Fertility and IVF Center, India Institute of Medical Sciences, New Delhi, India
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Barbados
| | - Dimple Desai
- DPU IVF & ENDOSCOPY CENTER, Dr. D. Y. Patil Hospital & Research Centre, Pune, India
| | - Masha Darbandi
- Fetal Health Research Center, Hope Generation Foundation, Tehran, Iran.,Gene Therapy and Regenerative Medicine Research Center, Hope Generation Foundation, Tehran, Iran
| | | | - Sara Darbandi
- Fetal Health Research Center, Hope Generation Foundation, Tehran, Iran.,Gene Therapy and Regenerative Medicine Research Center, Hope Generation Foundation, Tehran, Iran
| | | | | | - Sajal Gupta
- American Center for Reproductive Medicine, Cleveland, OH, USA
| | | | - Renata Finelli
- American Center for Reproductive Medicine, Cleveland, OH, USA
| | - Hassan N Sallam
- Department of Obstetrics and Gynaecology, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Kelly A Wirka
- Fertility & Endocrinology, Medical Affairs, EMD Serono, USA
| | - Florence Boitrelle
- Reproductive Biology, Fertility Preservation, Andrology, CECOS, Poissy Hospital, Poissy, France.,Department of Biology, Reproduction, Epigenetics, Environment and Development, Paris Saclay University, UVSQ, INRAE, BREED, Jouy-en-Josas, France
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland, OH, USA -
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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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Wang R, Seidler AL, Askie L, Norman RJ, Bhattacharya S, van Wely M, Mol BW. Network meta-analyses in reproductive medicine: challenges and opportunities. Hum Reprod 2020; 35:1723-1731. [PMID: 32662508 DOI: 10.1093/humrep/deaa126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 05/04/2020] [Indexed: 01/24/2023] Open
Abstract
Network meta-analysis allows researchers to synthesise both direct and indirect evidence, thus enabling simultaneous comparisons of multiple treatments. A relatively recent addition to evidence synthesis in reproductive medicine, this approach has become increasingly popular. Yet, the underlying assumptions of network meta-analyses, which drive the validity of their findings, have been frequently ignored. In this article, we discuss the strengths and limitations of network meta-analyses. In addition, we present an overview of published network meta-analyses in reproductive medicine, summarize their challenges and provide insights into future research opportunities.
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Affiliation(s)
- Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Anna Lene Seidler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Robert J Norman
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | | | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Performing the embryo transfer: a guideline. Fertil Steril 2017; 107:882-896. [DOI: 10.1016/j.fertnstert.2017.01.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 11/17/2022]
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Saravelos SH, Wong AWY, Chan CPS, Kong GWS, Li TC. How often does the embryo implant at the location to which it was transferred? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:106-112. [PMID: 26437908 DOI: 10.1002/uog.15778] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine how often the embryo implants exactly at the site of transfer and what additional factors may affect the eventual site of implantation in assisted reproductive technology (ART) cycles. METHODS This was a prospective observational study of women undergoing ART treatment in a tertiary university unit. Several factors inherent to the embryo transfer (ET), such as the location of the air bubbles and uterine contractility at 1 and at 60 min after ET were assessed with two-dimensional and three-dimensional (3D) ultrasound. In women in whom there was a resulting pregnancy, the position of the gestational sac (i.e. right, left, center or low) was subsequently assessed using 3D ultrasound, and predictors of its location were evaluated. RESULTS Of 239 recruited women with visualization of air bubbles at ET, 71 singleton gestational sacs were subsequently observed on 3D ultrasound. Overall, 40.8% (29/71) of embryos implanted at the location where the air bubbles were visualized at 1 min after ET, and 50.7% (36/71) implanted where the air bubbles were visualized at 60 min after ET (Cohen's kappa coefficients 0.21 and 0.37, respectively; comparison of agreement values: P = 0.28). Specifically, at 1 min the correspondence between the location of the air bubble and embryo implantation was 37.5% (6/16), 57.1% (8/14), 36.8% (7/19) and 36.4% (8/22) for right, left, central and lower uterus, respectively (4 × 4 contingency table, P < 0.01); at 60 min, the correspondence was 72.2% (13/18), 50.0% (9/18), 33.3% (8/24) and 85.7% (6/7), respectively (5 × 4 contingency table, P < 0.001). In addition, higher vs lower frequency of uterine contractions at 60 min was associated with different sites of implantation (5.6% (1/18), 11.1% (2/18), 27.8% (5/18) and 55.6% (10/18) vs 34.0% (18/53), 24.5% (13/53), 13.2% (7/53) and 28.3% (15/53) for right, left, central and lower uterus, respectively, P < 0.05). In particular, a high uterine contraction frequency following ET was associated with a twofold increased chance of the pregnancy implanting in the lower part of the uterine cavity (relative risk, 1.96 (95% CI, 1.08-3.56), P < 0.05). CONCLUSIONS The position of the air bubbles within the first 60 min of ET appears to predict the site of implantation in approximately half of cases, denoting an overall poor agreement. This implies significant embryo migration, and has important clinical implications, as it demonstrates that other factors such as uterine contractility may dictate where the embryo will eventually implant following transfer. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S H Saravelos
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - A W Y Wong
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - C P S Chan
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - G W S Kong
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - T-C Li
- Assisted Reproductive Technology Unit, Department of Obstetrics & Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Omidi M, Halvaei I, Mangoli E, Khalili MA, Razi MH. The effect of embryo catheter loading technique on the live birth rate. Clin Exp Reprod Med 2015; 42:175-80. [PMID: 26815646 PMCID: PMC4724603 DOI: 10.5653/cerm.2015.42.4.175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/28/2015] [Accepted: 11/11/2015] [Indexed: 11/06/2022] Open
Abstract
Objective Embryo loading (EL) is a major step in embryo transfer (ET) and affect on the success of in vitro fertilization (IVF). This study aimed to compare the effect of two different EL techniques on the rates of pregnancy and delivery in IVF/ET cycles. Methods 207 fresh ET and 194 Frozen-thawed ET (FET) cycles were included in this retrospective study. Two groups (A and B) were defined based on the EL technique used. In group A, the entire catheter was flushed with Ham's F-10 medium. The embryos were then drawn into the catheter using one air bracket. In group B, 70 µL of air was aspirated into the syringe and the catheter was flushed using Ham's F10 medium. The medium, air, embryos, air, and finally another layer of medium were then sequentially drawn into the catheter. The main outcome measures were the pregnancy and delivery rates. Results The groups did not differ with respect to the etiology of infertility, the source of spermatozoa, the quality of the embryos, the type of EL catheter, and the ease of transfer. The pregnancy rate was similar between two groups. In fresh ET cycles, a higher delivery rate was observed in group B than it group A (78.1% vs. 60%, p=0.1). In FET cycles, the rate of delivery was significantly higher in group B than in group A to a nonsignificant extent (88.9% vs. 58.8%, p=0.06). Conclusion EL techniques did not have a significant impact on the delivery rate in either fresh or FET cycles.
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Affiliation(s)
- Marjan Omidi
- Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Iman Halvaei
- Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Esmat Mangoli
- Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Ali Khalili
- Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Razi
- Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Abou‐Setta AM, Peters LR, D'Angelo A, Sallam HN, Hart RJ, Al‐Inany HG. Post-embryo transfer interventions for assisted reproduction technology cycles. Cochrane Database Syst Rev 2014; 2014:CD006567. [PMID: 25157849 PMCID: PMC11064760 DOI: 10.1002/14651858.cd006567.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In women undergoing in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), embryos transferred into the uterine cavity can be expelled due to many factors including uterine peristalsis and contractions, low site of deposition and negative pressure generated when removing the transfer catheter. Techniques to reduce the risk of embryo loss following embryo transfer (ET) have been described but are not standard in all centres conducting ET. OBJECTIVES To evaluate the efficacy of interventions used to prevent post-transfer embryo expulsion in women undergoing IVF and ICSI. SEARCH METHODS We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials to June 2014 and PubMed, MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, World Health Organization ICTRP, and trial registers from inception to June 2014, with no language restrictions. Additionally, we handsearched reference lists of relevant articles, and ESHRE and ASRM conference abstracts. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions used to prevent post-transfer embryo expulsion in women undergoing IVF and ICSI. Two review authors independently screened titles and abstracts and reviewed the full-texts of all potentially eligible citations to determine whether they met our inclusion criteria. Disagreements were resolved by consensus. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of included trials using standardised, piloted data extraction forms. Data were extracted to allow intention-to-treat analyses. Disagreements were resolved by consensus. The overall quality of the evidence was rated using GRADE methods. MAIN RESULTS We included four RCTs (n = 1392 women) which administered the following interventions: bed rest (two trials), fibrin sealant (one trial), and mechanical closure of the cervix (one trial). Our primary outcome, live birth rate, was not reported in any of the included trials; nor were the data available from the corresponding authors. For the ongoing pregnancy rate, two trials comparing more bed rest with less bed rest showed no evidence of a difference between groups (odds ratio (OR) 0.88; 95% confidence interval (CI) 0.60 to 1.31, 542 women, I(2) = 0%, low quality evidence). Secondary outcomes were sporadically reported with the exception of the clinical pregnancy rate, which was reported in all of the included trials. There was no evidence of a difference in clinical pregnancy rate between more bed rest and less bed rest (OR 0.88; 95% CI 0.60 to 1.31, 542 women, I(2) = 0%, low quality evidence) or between fibrin sealant and usual care (OR 0.98; 95% CI 0.54 to 1.78, 211 women, very low quality evidence). However, mechanical closure of the cervix was associated with a higher clinical pregnancy rate than usual care (OR 1.92; 95% CI 1.40 to 2.63, very low quality evidence). The quality of the evidence was rated as low or very low for all outcomes. The main limitations were failure to report live births, imprecision and risk of bias. Overall, the risk of bias of the included trials was high. The use of a proper method of randomisation and allocation concealment was fairly well reported, while only one trial clearly reported blinding. There was no evidence that any of the interventions had an effect on adverse event rates but data were too few to reach any conclusions. AUTHORS' CONCLUSIONS There is insufficient evidence to support any specific length of time for women to remain recumbent, if at all, following embryo transfer, nor is there sufficient evidence to recommend the use of fibrin sealants added to the embryo transfer fluid. There is very limited evidence to support the use of mechanical pressure to close the cervical canal following embryo transfer. Further well-designed and powered studies are required to determine the true effectiveness and safety of these interventions.
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Affiliation(s)
- Ahmed M Abou‐Setta
- University of ManitobaCentre for Healthcare InnovationGH‐714 820 Sherbrook StreetWinnipegMBCanadaR3A 1R9
| | - Leah R Peters
- University of LimerickGraduate Entry Medical SchoolLimerickIreland
| | - Arianna D'Angelo
- Cardiff University School of MedicineObstetrics and GynaecologyCardiffWalesUK
| | - Hassan N Sallam
- Alexandria UniversityObstetrics and Gynaecology22 Victor Emanuel SquareSmouhaAlexandriaEgypt21615
| | - Roger J Hart
- The University of Western Australia, King Edward Memorial Hospital and Fertility Specialists of Western AustraliaSchool of Women's and Infants' Health374 Bagot RoadSubiacoWestern AustraliaAustralia6008
| | - Hesham G Al‐Inany
- Faculty of Medicine, Cairo UniversityObstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
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Abuelghar WM, Elkady OS, Tamara TF, Khalil MH. Risk of first trimester spontaneous miscarriage among singleton gestations following ICSI and its relation to underlying cause of infertility. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Halvaei I, Khalili MA, Razi MH, Agha-Rahimi A, Nottola SA. Impact of different embryo loading techniques on pregnancy rates in in vitro fertlization/embryo transfer cycles. J Hum Reprod Sci 2013; 6:65-9. [PMID: 23869155 PMCID: PMC3713581 DOI: 10.4103/0974-1208.112385] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 06/02/2012] [Accepted: 09/27/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Embryo transfer (ET) technique is one of the important factors of in vitro fertlization success. Among the different steps in ET technique, less attention has been given to embryo loading (EL). The aim was to compare the impact of two different techniques of EL on pregnancy rate in IVF/ET cycles. MATERIALS AND METHODS In this retrospective study, 144 and 170 patients were placed in groups A and B, respectively. In Group A, the embryos were drawn directly into the ET catheter from culture microdrop under the oil. In Group B, the embryos were transferred from culture microdrop into G2 medium in center-well dish. Then, the embryos were drawn into the catheter and finally transferred into the uterus. Both groups were adjusted for other parameters based on the EL technique. The main outcome measure was pregnancy rate. RESULTS There were insignificant differences for etiology of infertility, source of sperm, type of stimulation protocol, percent of IVF or intracytoplasmic sperm injection type of ET catheter, cycles with good quality embryos and transferred embryos between two groups. The rate of both chemical and clinical pregnancy was higher in Group B compared to A, but the difference was insignificant (P = 0.09 and P = 0.1, respectively). CONCLUSION It seems that there is no difference in the outcome by loading the embryo from microdrop or center-well dish.
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Affiliation(s)
- Iman Halvaei
- Department of Clinical Embryology, Yazd Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Ressler IB, Pakrashi T, Sroga JM, DiPaola KB, Thomas MA, Lindheim SR. Effects of Embryo Transfer Catheters on the Endometrial Surface Noted at Hysteroscopy. J Minim Invasive Gynecol 2013; 20:381-5. [DOI: 10.1016/j.jmig.2013.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/06/2013] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
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Porat N, Boehnlein LM, Schouweiler CM, Kang J, Lindheim SR. Interim analysis of a randomized clinical trial comparing abdominal versus transvaginal ultrasound-guided embryo transfer. J Obstet Gynaecol Res 2010; 36:384-92. [DOI: 10.1111/j.1447-0756.2009.01148.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abou-Setta AM, D'Angelo A, Sallam HN, Hart RJ, Al-Inany HG. Post-embryo transfer interventions for in vitro fertilization and intracytoplasmic sperm injection patients. Cochrane Database Syst Rev 2009:CD006567. [PMID: 19821374 DOI: 10.1002/14651858.cd006567.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Techniques for embryo transfer (ET) are being developed, optimized, and standardized to provide the best outcomes.This includes methods to reduce the risk of embryo loss following ET. OBJECTIVES To systematically locate, analyse, and review the best available evidence regarding the effectiveness of post-ET techniques for women undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). SEARCH STRATEGY We searched electronic databases; reference lists of primary studies, review articles, and relevant publications; and conference abstracts. No language restrictions were applied. SELECTION CRITERIA Screening and selection of 2436 possible trial citations were performed independently by two review authors. Four prospective, truly randomised trials met the inclusion criteria. The trials compared two competing post ET interventions or an intervention versus no treatment in women undergoing IVF and ICSI. DATA COLLECTION AND ANALYSIS Two review authors independently collected data and assessed risk of bias using a standardized data extraction form. Individual outcome data were extracted to support an intention-to-treat analysis. MAIN RESULTS The primary outcome, live birth rate, was not reported in any of the included trials. The ongoing pregnancy rate was only available for one trial that compared immediate ambulation with 30 minute bed rest, with no evidence of an effect with bed rest (OR 1.00; 95% CI 0.54 to 1.85).Secondary outcomes were sporadically reported with the exception of clinical pregnancy rate, which was reported in all of the included trials. There was no significant difference between less bed rest and more rest (OR 1.13; 95% CI 0.77 to 1.67). Nor was there any significant difference between the use of a fibrin sealant and control (OR 0.98; 95% CI 0.54 to 1.78). Even so, there was a significantly higher probability of pregnancy following mechanical closure of the cervix compared with no intervention (OR 1.92; 95% CI 1.40 to 2.63).The risk of bias of the included studies was variable. The reporting of a proper method of randomisation and allocation concealment was demonstrated in the majority of trials, while only one trial was reported to be blinded. AUTHORS' CONCLUSIONS There is insufficient evidence to support a certain amount of time for women to remain recumbent following ET, or to support the use of fibrin sealants. Finally, there is limited evidence to support the use of mechanical closure of the cervical canal following ET. Further well-designed and powered studies are required to determine the true effect, if any, of these and other post ET techniques for women undergoing IVF and ICSI.
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Affiliation(s)
- Ahmed M Abou-Setta
- University of Alberta Evidence-based Practice Centre (UA-EPC), Alberta Research Centre for Health Evidence (ARCHE), Aberhart Centre One, Room 8412, 11402 University Avenue, Edmonton, Edmonton, Canada, T6G 2J3
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Edwards SJ, Clarke MJ, Wordsworth S, Borrill J. Indirect comparisons of treatments based on systematic reviews of randomised controlled trials. Int J Clin Pract 2009; 63:841-54. [PMID: 19490195 DOI: 10.1111/j.1742-1241.2009.02072.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Randomised controlled trials are the most effective way to differentiate between the effects of competing interventions. However, head-to-head studies are unlikely to have been conducted for all competing interventions. AIM Evaluation of different methodologies used to indirectly compare interventions based on meta analyses of randomised controlled trials. METHODS Systematic review of Cochrane Database of Systematic Reviews, Cochrane Methodology Register, EMBASE and MEDLINE for reports including meta analyses that contained an indirect comparison. Searching was completed in July 2007. No restriction was placed on language or year of publication. RESULTS Sixty-two papers identified contained indirect comparisons of treatments. Five different methodologies were employed: comparing point estimates (1/62); comparing 95% confidence intervals (26/62); performing statistical tests on summary estimates (8/62); indirect comparison using a single common comparator (20/62); and mixed treatment comparison (MTC) (7/62). The only methodologies that provide an estimate of the difference between the interventions under consideration and a measure of the uncertainty around that estimate are indirect comparison using a single common comparator and MTC. The MTC might have advantages over other approaches because it is not reliant on a single common comparator and can incorporate the results of direct and indirect comparisons into the analysis. Indirect comparisons require an underlying assumption of consistency of evidence. Utilising any of the methodologies when this assumption is not true can produce misleading results. CONCLUSIONS Use of either indirect comparison using a common comparator or MTC provides estimates for use in decision making, with the preferred methodology being dependent on the available data.
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Affiliation(s)
- S J Edwards
- Kellogg College, University of Oxford, Oxford, UK.
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SALDEEN P, ABOUSETTA A, BERGH T, SUNDSTROM P, HOLTE J. A prospective randomized controlled trial comparing two embryo transfer catheters in an ART program. Fertil Steril 2008; 90:599-603. [DOI: 10.1016/j.fertnstert.2007.06.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Revised: 06/27/2007] [Accepted: 06/27/2007] [Indexed: 10/22/2022]
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Among women undergoing embryo transfer, is the probability of pregnancy and live birth improved with ultrasound guidance over clinical touch alone? A systemic review and meta-analysis of prospective randomized trials. Fertil Steril 2007; 88:333-41. [DOI: 10.1016/j.fertnstert.2006.11.161] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Revised: 11/27/2006] [Accepted: 11/27/2006] [Indexed: 11/30/2022]
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Abou-Setta AM. What is the best site for embryo deposition? A systematic review and meta-analysis using direct and adjusted indirect comparisons. Reprod Biomed Online 2007; 14:611-9. [PMID: 17509204 DOI: 10.1016/s1472-6483(10)61054-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Abou-Setta AM, D'Angelo A, Hart RJ, Sallam HN. Post embryo transfer interventions for in vitro fertilization / intracytoplasmic sperm injection patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abou-Setta AM. Air fluid versus fluid-only models of embryo catheter loading: a systematic review and meta-analysis. Reprod Biomed Online 2007; 14:80-4. [PMID: 17207337 DOI: 10.1016/s1472-6483(10)60767-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The objective of this systematic review was to determine the beneficial or detrimental effect of using air bubbles to bracket the embryo-containing medium during embryo transfer. To test this theory, a meta-analysis of randomized trials comparing air fluid versus fluid-only methods was performed. The primary outcome measures were live birth, ongoing and clinical pregnancy rates. The secondary outcome measures were the rates of implantation, miscarriage, multiple and ectopic pregnancies and retained embryos. Electronic (e.g.PubMed, EMBASE, Cochrane Library) and hand searches of the literature revealed two included studies (298 women). Meta-analysis was conducted using the Mantel-Haenszel method (fixed-effect model). For the primary outcome measures, there were no significant differences between the two methods with regards to live birth (OR = 1.34; 95% CI = 0.59-3.07), ongoing pregnancy (OR = 1.34; 95% CI = 0.59-3.07) and clinical pregnancy (OR = 1.13; 95% CI = 0.70-1.83) rates. For the secondary outcomes, there were no significant differences between the two groups. In conclusion there is insufficient evidence to suggest that the fluid-only method is superior to the use of air brackets during embryo loading. There is a need for well-designed and powered randomized trials to determine any possible benefit to either method.
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Eskandar MA, Abou-Setta AM, El-Amin M, Almushait MA, Sobande AA. Removal of cervical mucus prior to embryo transfer improves pregnancy rates in women undergoing assisted reproduction. Reprod Biomed Online 2007; 14:308-13. [PMID: 17359583 DOI: 10.1016/s1472-6483(10)60872-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The removal of cervical mucus during embryo transfer has been postulated to increase the pregnancy and implantation rates by not interfering with embryo implantation. Even so, this is a time-consuming procedure that may increase the incidence of difficult transfers by removing the naturally lubricant mucus. In addition, any cervical manipulations at the time of embryo transfer may cause unwarranted uterine contractions. In this prospective, controlled study, 286 women undergoing embryo transfer between January and May 2006 were divided into two groups according to whether the cervical mucus was scheduled to be aspirated (group A) or not (group B). The two groups were similar with regards to the demographics, cause of infertility, characteristics of ovarian stimulation and embryos transferred. Even so, the clinical pregnancy rate was significantly higher in group (A) than group (B) (OR = 2.18, 95% CI = 1.32-3.58), although there were easier transfers in group (B) than group (A) (OR = 3.00, 95% CI = 1.05-8.55). This demonstrates that even though embryo transfers were easier to perform when the cervical mucus was left in place, aspiration resulted in an increased chance of clinical pregnancy.
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Affiliation(s)
- Mamdoh A Eskandar
- Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia.
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Visschers BAJT, Bots RSGM, Peeters MF, Mol BWJ, van Dessel HJHM. Removal of cervical mucus: effect on pregnancy rates in IVF/ICSI. Reprod Biomed Online 2007; 15:310-5. [PMID: 17854530 DOI: 10.1016/s1472-6483(10)60344-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cervical mucus may cover the embryo transfer catheter during passage of the cervical canal, interfering with the correct placement of the embryo(s) into the uterine cavity. The effect of removal of cervical mucus prior to embryo transfer in IVF/ intracytoplasmic sperm injection (ICSI) on live birth rate was studied. The study was set up as a single blind randomized controlled trial. Couples undergoing IVF/ICSI were randomly allocated to either removal of cervical mucus prior to embryo transfer, or a mock procedure. Randomization was done with stratification for age, cycle number and method of treatment. Primary outcome was live birth rate. A total of 317 couples were included and underwent 428 cycles, of which the outcome of 3 cycles was unknown. Baseline characteristics of both groups were comparable. Live birth occurred in 52 of 220 (24%) cycles in the treatment group and 42 of 205 (21%) cycles in the control group (risk difference 3%, 95% confidence interval-5- 11%). It is unlikely that removal of cervical mucus prior to embryo transfer has a significant effect on live birth rate. A small effect, however, cannot be excluded.
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Affiliation(s)
- B A J T Visschers
- Department of Obstetrics and Gynaecology, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
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Cavagna M, Contart P, Petersen CG, Mauri AL, Martins AMC, Baruffi RLR, Oliveira JBA, Franco JG. Implantation sites after embryo transfer into the central area of the uterine cavity. Reprod Biomed Online 2006; 13:541-6. [PMID: 17007675 DOI: 10.1016/s1472-6483(10)60642-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A total of 63 pregnancies (47 singleton, 15 twin, 1 triplet) from intracytoplasmic sperm injection cycles were analysed. In all embryo transfers, the catheter was introduced into the endometrial cavity guided by abdominal ultrasound, with the catheter tip placed at the middle point of the endometrial cavity. Gestational sacs (GS) were located 21-24 days after transfer (gestational age=5 weeks) by two-dimensional and three-dimensional transvaginal ultrasound. The uterine cavity was divided into three parts: upper, middle and lower. Furthermore, the upper region was subdivided into right, middle and left areas, and the middle region was subdivided into right and left areas. The frequency of gestational sacs in each area was evaluated. In singleton pregnancies 66.0% (31/47) of the GS were detected in the upper region, 29.8% (14/47) in the middle region and 4.2% (2/47) in the lower region. In multiple pregnancies (twins and triplet) 45.5% (15/33) of the GS were detected in the upper region, 51.5% (17/33) in the middle region and 3.0% (1/33) in the lower region. In conclusion, the results demonstrate that when embryos are transferred to the central area of the uterine cavity there is an increase in implantation rate in the middle region compared with the rate expected in naturally conceived pregnancies (9-15%).
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Affiliation(s)
- M Cavagna
- Center for Human Reproduction Prof. Franco Junior, Av. Prof. João Fiusa, 689-CEP 14025-310, Ribeirão Preto, SP, Brazil
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Cevrioglu AS, Esinler I, Bozdag G, Yarali H. Assessment of endocervical and endometrial damage inflicted by embryo transfer trial: a hysteroscopic evaluation. Reprod Biomed Online 2006; 13:523-7. [PMID: 17007673 DOI: 10.1016/s1472-6483(10)60640-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim was to assess the endocervical and endometrial damage inflicted by embryo transfer trial using office hysteroscopy. Seventy-five consecutive infertile women who underwent office hysteroscopy were enrolled. Hysteroscopy was performed immediately after embryo transfer trial. The relationship between clinical perception of easiness of transfer, presence of blood on the catheter, degree of endocervical and endometrial damage was examined. In the difficult transfer group, minor and moderate endocervical lesions were noted in 35% and 24% of the cases, respectively. The respective figures for the easy transfer group were 19% and 3% (P>.05). There was a statistically significant concordance between the perceived difficulty of transfer and degree of endometrial damage (P<0.05). Of interest, in the easy transfer group, 32% of the patients had minor, 3% moderate and 65% no endometrial damage. The respective figures were 42%, 29% and 29% in the difficult transfer group. There was blood on the catheter in 25%, 56% and 71% of the easy, moderate and difficult transfer groups, respectively. There was a statistically significant concordance between the perceived difficulty of embryo transfer and presence of blood on the catheter (P<0.05). These results suggest that clinical perception of difficulty of transfer and the presence of blood on the catheter are directly associated with endometrial disruption.
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Affiliation(s)
- Arif Serhan Cevrioglu
- Department of Obstetrics and Gynecology, Afyon Kocatepe University Faculty of Medicine, 03200, Afyon, Turkey.
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