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Nancarrow L, Tempest N, Lane S, Homburg R, Russell R, Hapangama DK. Four-dimensional ultrasound guided embryo transfers improve live birth rates when compared to the clinical touch technique: a randomised controlled trial. Sci Rep 2023; 13:14875. [PMID: 37684296 PMCID: PMC10491625 DOI: 10.1038/s41598-023-41313-z] [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: 03/26/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Most aspects of in-vitro fertilisation (IVF) have changed dramatically since introduction, but embryo transfer (ET) technique remains largely unaltered. We aimed to determine whether four-dimensional ultrasound guided embryo transfers (4D UGET) could improve pregnancy rates when compared with clinical touch technique (CTT). This was a single centre open labelled randomised controlled trial in a tertiary fertility centre in the UK. 320 women were randomised on the day of single ET. The primary outcome was clinical pregnancy rate (CPR), secondary outcomes included live birth rate (LBR), biochemical pregnancy rate (BPR), miscarriage, pregnancy of unknown location (PUL) and ectopic pregnancy. 4D-UGET resulted in significantly higher CPR [50% vs 36% p = 0.02, OR 1.78 (1.12-2.84)] and LBR [41% vs 28%, p = 0.02, OR 1.77 (1.09-2.87)] when compared to CTT technique. Miscarriage (p = 0.49), PUL (p = 0.14) and ectopic pregnancy (p = 0.96) were similar between the two groups. LBR, from this trial, are significantly higher than the current UK average (41% vs 24%). 4D UGET allows for superior imaging of the uterine cavity, whilst tailoring the embryo deposition point specifically to the patient. Further RCTs are required to determine if these results can be replicated in other units and whether 4D UGET is superior to 2D UGET.
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Affiliation(s)
- L Nancarrow
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Centre for Women's Health Research, Member of Liverpool Health Partners, University of Liverpool, Liverpool, L8 7SS, UK
- Hewitt Centre for Reproductive Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, L8 7SS, UK
| | - Nicola Tempest
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Centre for Women's Health Research, Member of Liverpool Health Partners, University of Liverpool, Liverpool, L8 7SS, UK.
- Hewitt Centre for Reproductive Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, L8 7SS, UK.
- Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK.
| | - S Lane
- Department of Biostatistics, Institute of Life Course and Medical Sciences, Member of Liverpool Health Partners, University of Liverpool, Liverpool, UK
| | - R Homburg
- Hewitt Centre for Reproductive Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, L8 7SS, UK
| | - R Russell
- Hewitt Centre for Reproductive Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, L8 7SS, UK
- Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - D K Hapangama
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Centre for Women's Health Research, Member of Liverpool Health Partners, University of Liverpool, Liverpool, L8 7SS, UK
- Liverpool Women's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
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Mizrachi Y, McQueen DB. Embryo transfer success: It is in our hands. Fertil Steril 2022; 118:815-819. [PMID: 36192230 DOI: 10.1016/j.fertnstert.2022.08.858] [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: 07/01/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Abstract
Embryo transfer (ET) is considered as a critical step in the process of in vitro fertilization. Interestingly, studies have consistently shown significant outcome differences between physicians. Although the outcome of ET is not related to the physician's experience and specifically not different between fellows and attending physicians, certain techniques have been found to affect the success rate. This review summarizes the existing evidence regarding the impact of the individual physician performing ET and the techniques used.
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Affiliation(s)
- Yossi Mizrachi
- Reproductive Services Unit, The Royal Women's Hospital, and University of Melbourne, Victoria, Australia
| | - Dana B McQueen
- Reproductive Medicine Associates, San Francisco, California.
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Tyler B, Walford H, Tamblyn J, Keay SD, Mavrelos D, Yasmin E, Al Wattar BH. Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses. Hum Reprod Update 2022; 28:480-500. [PMID: 35325124 PMCID: PMC9631462 DOI: 10.1093/humupd/dmac009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists. OBJECTIVE AND RATIONALE We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes. SEARCH METHODS We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses. OUTCOMES Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs. WIDER IMPLICATIONS Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.
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Affiliation(s)
- Bede Tyler
- UCL Institute for Women's Health, University College London, London, UK
| | - Hugo Walford
- UCL Institute for Women's Health, University College London, London, UK
| | - Jennifer Tamblyn
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Stephen D Keay
- Centre for Reproductive Medicine, University Hospital of Coventry & Warwickshire, Coventry, UK
| | - Dimitrios Mavrelos
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Ephia Yasmin
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Bassel H Al Wattar
- Correspondence address. Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK, WC1E 6DB. E-mail:
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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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Nouri K, Tempfer CB, Walch K, Promberger R, Dag S, Ott J. Predictive value of the time interval between embryo loading and transfer for IVF/ICSI success: a prospective cohort study. Reprod Biol Endocrinol 2015; 13:51. [PMID: 26022289 PMCID: PMC4455943 DOI: 10.1186/s12958-015-0048-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Kazem Nouri
- Department of Obstetrics and Gynecology, Clinical Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Clemens B Tempfer
- Department of Obstetrics and Gynecology, Ruhr University Bochum, Bochum, Germany.
- Marienhospital Herne, Hoelkeskampring 40, 44625, Herne, Germany.
| | - Katharina Walch
- Department of Obstetrics and Gynecology, Clinical Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Regina Promberger
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Sema Dag
- Department of Obstetrics and Gynecology, Clinical Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Johannes Ott
- Department of Obstetrics and Gynecology, Clinical Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Yao Z, Vansteelandt S, Van der Elst J, Coetsier T, Dhont M, De Sutter P. The efficacy of the embryo transfer catheter in IVF and ICSI is operator-dependent: a randomized clinical trial. Hum Reprod 2008; 24:880-7. [PMID: 19095665 DOI: 10.1093/humrep/den453] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zhan Yao
- Department of Obstetrics and Gynaecology, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium
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Aboulfotouh I, Abou-Setta AM, Khattab S, Mohsen IA, Askalani A, El-Din RE. Firm versus soft embryo transfer catheters under ultrasound guidance: Does catheter choice really influence the pregnancy rates? Fertil Steril 2008; 89:1261-1262. [PMID: 17644096 DOI: 10.1016/j.fertnstert.2007.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 04/14/2007] [Accepted: 05/01/2007] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ismail Aboulfotouh
- The International Egyptian IVF Center, Cairo, Egypt; Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Sherif Khattab
- The International Egyptian IVF Center, Cairo, Egypt; Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Iman Abdel Mohsen
- The International Egyptian IVF Center, Cairo, Egypt; Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Askalani
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Ata B, Yakin K, Alatas C, Urman B. Dual renin-angiotensin blockage and total embryo cryopreservation is not a risk-free strategy in patients at high risk for ovarian hyperstimulation syndrome. Fertil Steril 2007; 90:531-6. [PMID: 18001715 DOI: 10.1016/j.fertnstert.2007.07.1309] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 06/23/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of dual renin-angiotensin system (RAS) blockage together with total embryo cryopreservation for prevention of ovarian hyperstimulation syndrome (OHSS) in overstimulated patients undergoing IVF. DESIGN Retrospective case series. SETTING A private tertiary care hospital assisted reproduction program. PATIENT(S) Ten women at high risk for OHSS (mean E(2) level 9401 +/- 585 pg/mL on the day of hCG administration). INTERVENTION(S) Cancellation of ET and dual RAS blockage with an angiotensin receptor blocker (candesartan cilexetil) and an angiotensin-converting enzyme inhibitor (enalapril) starting from day 1 after oocyte retrieval. Embryos were cryopreserved and transferred in subsequent cycles. MAIN OUTCOME MEASURE(S) Development of OHSS and pregnancy and live birth rates after frozen-thawed ETs. RESULT(S) While eight women did not develop OHSS, two women (20%) developed severe OHSS requiring hospitalization. Subsequent frozen-thawed ETs resulted in an 80% clinical pregnancy rate and 40% live birth rate. CONCLUSION(S) Dual RAS blockage with total embryo cryopreservation is a relatively new strategy that was proposed for use in patients at high risk for OHSS. It should be stressed that complete elimination of the syndrome is not possible with this treatment. Subsequent pregnancy rates with the transfer of frozen-thawed embryos are high.
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Affiliation(s)
- Baris Ata
- Assisted Reproduction Unit of the American Hospital of Istanbul, Istanbul, Turkey.
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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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