Predictors of success after embryo transfer: experience from a single provider

Do vitrified frozen-thawed embryos generated from successful fresh cycles have higher potential for favorable outcome?

BACKGROUND

Many variables, including woman's age, embryo quality and endometrial receptivity, influence the success rate of either fresh embryo transfer (ET) or frozen-thawed ET (FT-ET) cycles. This study aims to examine whether the results of a fresh in-vitro fertilization (IVF) cycle correlate with its frozen-thawed embryos transfer outcomes.

METHODS

A retrospective cohort study conducted in a tertiary medical center single IVF unit between 2014-2017. The study population was comprised of women who underwent fresh ET with the remaining embryos frozen using vitrification and at least one consecutive FT-ET cycle. Comparison of FT-ET cycle's details and outcomes were assessed in relation to the outcome of preceding fresh ET cycle.

RESULTS

A total of 599 women underwent fresh ET and at least one consecutive FT-ET cycle. Significantly higher rates of successful FT-ET cycle outcomes were observed in the group of patients with a successful fresh cycle compared to the group with an unsuccessful fresh cycle (48.9% vs. 20.8%, P<0.001). Logistic regression demonstrated an adjusted OR of 5.02 for successful FT-ET after a successful fresh cycle.

CONCLUSIONS

Frozen-thawed embryos generated from successful fresh IVF cycles have higher potential to implant when compared to frozen-thawed embryos obtained in an unsuccessful fresh cycle.

One step further: randomised single-centre trial comparing the direct and afterload techniques of embryo transfer

STUDY QUESTION

What are the differences in ease of use between two different embryo transfer (ET) techniques: the preload direct approach and the afterload approach.

SUMMARY ANSWER

The afterload technique seems to reduce the rate of difficult ETs.

WHAT IS KNOWN ALREADY

Numerous published trials now document that the ET procedure has an impact on pregnancy and delivery rates after IVF. Difficult transfers should be avoided, as they reduce implantation and pregnancy rates. Preload direct ETs with soft catheters under ultrasound guidance is currently considered the best procedure. However, when using soft catheters, it is not known which technique is preferable or which one should be implemented to reduce the operator factor.

STUDY DESIGN, SIZE, DURATION

This prospective randomised unblinded controlled clinical trial, included 352 ultrasound-guided ETs assigned to either direct ET or afterload ET, between September 2017 and March 2019. The sample size was calculated based on the historical rate of difficult ETs encountered between 2014 and 2015 with a direct ET procedure.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were women 18-38 years old, with BMI between 18 and 28, receiving a single-thawed blastocyst transfer. The exclusion criteria were use of testicular sperm and preimplantation genetic testing (PGT) cycles. The primary outcome was the rate of difficult or suboptimal transfers defined as: advancement of the outer sheath (specific for the direct transfer), multiple attempts, use of force, required manipulation, use of a stylet or tenaculum, dilatation, or use of a different catheter. The secondary outcome was clinical pregnancy rate.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 352 frozen ETs were randomised, with 176 patients in each group. The two arms were homogeneous for female and male age, female BMI, duration of infertility, secondary infertility, previous deliveries or miscarriages, myomas, previous surgery to the uterine cavity, cycle day at ovulation trigger, freeze all cycles, first transfers, indication for treatment, endometrial preparation protocol and duration, endometrial thickness, and blastocyst grade at vitrification. Across the entire population, 85 (24.1%) ETs were defined as difficult. The rate of difficult transfers was significantly higher in the direct ET group than in the afterload group: 68 (38.6%) versus 17 (9.7%), respectively (OR 0.17, 95% CI 0.09-0.30, P < 0.001). The mean percentage in the rate of difficult transfers per operator was 22.5% (SD ± 14.5%), of which 36.1% (SD ± 23.4%) were in the direct group compared with 8.6% (± 8.2%) in the afterload group (P < 0.001). The difficult transfer rate among operators varied from 0 to 43.8% (0-77.8% in the direct group and 0 to 25.0% in the afterload group). The clinical pregnancy rates (42.0% vs 48.3%, P = 0.239 in the direct and afterload groups, respectively) were not significantly different between the groups.

LIMITATIONS, REASONS FOR CAUTION

There were 18 experienced operators who participated in the trial. Conclusions about the pregnancy rate should not be generalised, since the sample analysis was not performed on this outcome and, although clinically relevant, the difference was not significantly different.

WIDER IMPLICATIONS OF THE FINDINGS

The rate of difficult transfers was significantly higher in the direct ET group compared with the afterload ET group, although a wide variation was observed among operators. Further studies regarding the association between transfer technique and ART outcomes are required.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was sought and there are no competing interests.

TRIAL REGISTRATION NUMBER

NCT03161119.

TRIAL REGISTRATION DATE

5 April 2017.

DATE OF FIRST PATIENT'S ENROLMENT

26 September 2017.

The effect of embryo transfer technique on pregnancy rates in in vitro fertilization-intracytoplasmic sperm injection cycles: A prospective cohort study

Objective:

To investigate whether embryo transfer affects pregnancy rates in in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) treatment.

Materials and Methods:

A total of 2,257 patients who underwent IVF-ICSI treatment between 2012 and 2017 were included in this study. Subjects were categorized according to the embryo transfer technique that was required: group 1 (n=1,657) underwent easy transfer with a soft catheter; group 2 (n=548) received external guidance transfers; and group 3 (n=52) experienced difficult transfers with a stylet. Basal parameters, clinical and laboratory IVF-ICSI outcomes, and clinical pregnancy rates (CPR) were compared between the groups.

Results:

There were no differences between the groups in terms of age, body mass index, smoking status, duration and etiology of infertility, baseline folliclestimulating hormone, luteinizing hormone, estradiol (E₂), thyroid-stimulating hormone, prolactin levels, antral follicle count, duration of stimulation, stimulation protocol, total gonadotropin dose required, peak E₂ levels, progesterone levels, and endometrial thickness on human chorionic gonadotropin administration and transfer days (p>0.05). The numbers of oocytes retrieved, MII and 2PN, fertilization rate, day of embryo transfer, and CPRs were also comparable between the groups (p>0.05).

Conclusion:

Our data suggest that embryo transfer has no impact on pregnancy rates in patients who undergo IVF-ICSI treatment. Further studies with more participants are required to elucidate this situation.

Does the Time of Starting Progesterone Luteal Support Affect Embryo Transfer in Long Agonist Protocol Downregulated ICSI Cycles? A Randomized Controlled Trial

The aim of this study was to compare the effects of starting progesterone (P4) luteal support (LS) on day of egg retrieval (ER) or day of embryo transfer (ET) on the ratio of difficult ET and cycle outcome. This was a RCT ( ClinicalTrials.gov Identifier: NCT03040830) carried out at Mansoura Integrated Fertility Center (MIFC), Mansoura, Egypt, from November 2015 to January 2017. A total of 171 eligible long agonist ICSI cases were randomly allocated on day of ER into group A (86) starting LS as daily IM 100 mg P4 on day of ER and group B (85) starting P4-LS on day of ET. Difficult ET was defined as blood on ET catheter and/or sounding or dilating the cervix. Primary outcome was the overall ratio of difficult ET and ratios on day 3 and 5 ET. Secondary outcome was the ongoing pregnancy rate (OPR) and implantation rate (IR). The results are presented as % for groups A and B respectively: overall difficult ET (44.1, 24.7) (p = 0.009); day 3 difficult ET (23.2, 24.4) (p = 0.45); day 5 difficult ET (62.7, 25.6) (p = 0.001); overall OPR (38.3, 44.7) (p = 0.43); day 3 ET OPR (41.8, 33.3) (p = 0.51); day 5 ET OPR (34.8, 57.5) (p = 0.048); overall IR (20.0, 22.5) (p = 0.62); day 3 ET IR (17.8, 13.4) (p = 0.44); day 5 ET IR (22, 34.1) (p = 0.09). In conclusion, starting P4 luteal support on egg retrieval day is associated with significantly higher ratio of difficult embryo transfer and lower ongoing pregnancy rate and tendency to lower IR in day 5 ET, so starting P4-LS on day of ET is recommended.

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.

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.

Effect of the afterloaded external guidance embryo transfer technique on pregnancy rates in single embryo transfer cycles

OBJECTIVE

To investigate effect of the afterloaded external guidance embryo transfer technique on pregnancy rates in single embryo transfer intracytoplasmic sperm injection (ICSI) cycles.

MATERIAL AND METHODS

This retrospective study was performed at the Dr. Zekai Tahir Burak Women's Health Research and Education Hospital. Three hundred and thirteen women who underwent ICSI were included in the study. Subjects were categorized according to the embryo transfer technique; Group 1 (n: 232): easy transfer with a soft catheter, Group 2 (n: 45): after external guidance transfer, and Group 3 (n: 36): difficult transfer with a stylet. Basal parameters, clinical and laboratory IVF outcomes and pregnancy rates were studied.

RESULTS

Infertility etiology, basal follicle stimulating hormone (FSH) levels, antral follicle count, duration of stimulation, total dose of gonadotropin, peak estradiol levels, endometrial thickness, oocyte number, 2 PN, and fertilization rate were similar between the three groups (p>0.05). Despite the decreased pregnancy rate in Group 3, there were no differences in clinical pregnancy rates among the groups (p=0.204).

CONCLUSION

Embryo transfer is one of the critical steps in assisted reproduction procedures. Using the afterloaded external guidance embryo transfer technique did not improve pregnancy rates.

Correlation of technical difficulty during embryo transfer with rate of clinical pregnancy

AIM

To correlate the ease or difficulty of embryo transfer and blood at catheter tip with pregnancy rate when embryo transfer (ET) was performed by the same operator using soft catheter.

MATERIALS AND METHODS

A retrospective analysis of 342 patients who underwent in vitro fertilization or ICSI cycle from January 2008 to December 2010 in a single centre was done. The type of transfer was divided into two groups: 'easy' or 'difficult'. Transfer was considered difficult when additional instrumentation was required or firmer catheter was used or required changing of catheter. Patients undergoing cryo-preserved ET were excluded from the study.

RESULTS

On the day of transfer in 284 (83%) patients, ET was easy and difficulty was encountered in 58 (17%) patients. Blood at catheter was seen in 101 (29.53%) patients. In the group of 58 difficult transfers, 10 pregnancies resulted with a clinical pregnancy rate of 17.2%, while 67 pregnancies resulted in 284 cycles of easy transfer with clinical pregnancy rate of 23.6% (P value = 0.045). While no significant difference was seen in pregnancies with blood on outer catheter and blood less transfer, there was significant reduction in pregnancy rate when blood was present on catheter tip compared to bloodless transfer (13.3% v/s 24.1; P value = 0.032).

CONCLUSION

Reduction in clinical pregnancy rate is seen with difficult ETs, more when blood is present at the catheter tip.

A decrease in serum estradiol levels after human chorionic gonadotrophin administration predicts significantly lower clinical pregnancy and live birth rates in in vitro fertilization cycles

BACKGROUND

Although close observation of serum estradiol (E2) levels remains a mainstay of assessing clinical response to controlled ovarian stimulation, the prognostic value of any change in E2 levels after administration of hCG remains unclear. The objective of this study is to evaluate the relationship between serum E2 response after hCG administration and the clinical pregnancy and live birth rates in fresh IVF cycles.

METHODS

We conducted a retrospective cohort study of women aged 21-45 years undergoing their first IVF cycle from 1999 to 2008 at a single practice. We compared the post-hCG serum E2 level with values on the day of hCG trigger. IVF cycles were stratified by post-hCG E2 response and appropriate parametric and non-parametric statistics were performed. Clinical intrauterine pregnancy and live births were the primary outcomes of interest. Multivariable logistic regression models were created to identify predictive factors associated with outcomes while adjusting for potential confounders.

RESULTS

Among the 1712 IVF cycles, 1065 exhibited a >10% increase (Group A), 525 had a plateau (± 10%, Group B) and 122 showed a >10% decrease (Group C) in post-hCG E2 levels. While the E2 levels on the day of hCG were similar across groups, Group C had more patients with diminished ovarian reserve, required higher gonadotrophin doses and had the lowest implantation rates. After adjusting for age, total gonadotrophin dose, infertility diagnosis, number of oocytes and number of transferred embryos, the associations between post-hCG E2 decline (Group C) and clinical pregnancy [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.33-0.84, P= 0.007] and live birth (aOR: 0.40; 95% CI: 0.22-0.71, P= 0.002) were significant. We also found significant associations between E2 plateau (Group B) and clinical pregnancy (aOR: 0.73; 95% CI: 0.57-0.94, P= 0.013) and live birth (aOR: 0.74; 95% CI: 0.56-0.97, P= 0.032) when adjusting for the same factors.

CONCLUSIONS

In our study, >10% decrease in E2 levels after hCG administration was associated with 40-50% reduction in clinical pregnancy and live birth rates. Similarly, post-hCG E2 plateau (± 10%) lowered the clinical pregnancy and live birth rates by >25%. Our study suggests that the change in the post-hCG E2 level is another parameter that can be used by clinicians to counsel patients regarding their likelihood of success with assisted reproductive technologies prior to oocyte retrieval.

Quality Management Issues in the Assisted Reproduction Laboratory

In the United States, the Clinical Laboratory Improvement Act (CLIA) of 1988 describes requirements and guidelines for implementing a quality control/quality assurance (QC/QA) program for moderate and high complexity laboratories. These requirements and guidelines apply to Assisted Reproductive Technology (ART) laboratories as well. The general topic of QC and QA as it pertains to in vitro fertilization (IVF) and embryo transfer (ET) is extensively reviewed. This review summarizes many of the QC and QA events that contribute to the advancement of knowledge in this biotechnological field. These events include control of the culture environment inside and outside of the incubator, as well as factors that affect culture media. This review also discusses, in considerable detail, the QC and the QA that pertain to equipment used within the laboratory and how to control for potential contaminants, which reside within the laboratory. This review provides evidence to indicate the need for laboratory personnel to monitor quality improvement issues on a continuous basis. Personnel must be willing to change as improvements in technology occur in order to meet the ever-evolving demands of a more difficult patient population. Suggestions for meeting these demands are offered.

Hysteroscopic evaluation of endocervical and endometrial lesions observed after different procedures of embryo transfer: a prospective comparative study

OBJECTIVE

Endocervical and endometrial damage observed after different procedures of embryo transfer (ET) were investigated using diagnostic hysteroscopy.

STUDY DESIGN

Prospective, descriptive and comparative study, in an Infertility centre, University Hospital. Hundred consecutive infertile patients with a normal uterine cavity, included in an IVF program, were enrolled between May 1st, 2006 and April 30th, 2007. All the patients had a diagnostic hysteroscopy immediately after trial ET using soft ET catheters: (i) IVF Sydney Set (Cook, Limerick, Ireland) (n=27), (ii) Elliocath (Ellios, Paris, France) (n=34), (iii) Frydman classic 4.5 (CCD, Paris, France) (n=19), and rigid ET catheters: Memory Frydman 4.5 (CCD, Paris, France) (n=20). All the procedures were recorded and blindly reviewed. Data were analyzed using a Kruskal-Wallis test for age and severity of endometrial lesions, or Fisher's exact test for binary criteria.

RESULTS

Endocervical lesions were more frequently encountered in the soft (63%) and rigid (85%) Frydman's catheter groups compared to other groups (Elliocath: 29%, IVF Sydney Set: 26%; p<0.0001). Presence of blood on the catheter, and endometrial lesions were significantly less frequent in soft catheter groups compared to the rigid catheter group (p<0.0001). Severe endometrial lesions were less frequently observed when soft catheters were used (85%, 53%, 32%, 11% for Memory Frydman, Frydman classic, Elliocath and IVF Sydney Set, respectively; p<0.0001). The presence of blood on the catheter signed severe endometrial lesions.

CONCLUSION

All ET catheters can lead to endocervical and endometrial damage. Severe endometrial lesions were less frequent when soft catheters were used.

Endometriosis and infertility: epidemiology and evidence-based treatments

Endometriosis is an estrogen-dependent disorder defined as the presence of endometrial tissue outside of the uterine cavity. A leading cause of infertility, endometriosis has a prevalence of 0.5-5% in fertile and 25-40% in infertile women. The optimal choice of management for endometriosis-associated infertility remains obscure. Removal or suppression of endometrial deposits by medical or surgical means constitutes the basis of endometriosis management. Current evidence indicates that suppressive medical treatment of endometriosis does not benefit fertility and should not be used for this indication alone. Surgery is probably efficacious for all stages of the disease. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis when pelvic anatomy is normal. In advanced cases, in vitro fertilization is a treatment of choice, and its success may be augmented with prolonged gonadotropin-releasing hormone analog treatment. Further randomized clinical trials focusing on diverse etiopathogenic mechanisms and therapeutic innovation are necessary to find more conclusive, evidence-based answers regarding this enigmatic disease.

Optimizing the number of cleavage stage embryos to transfer on day 3 in women 38 years of age and older: a Society for Assisted Reproductive Technology database study

OBJECTIVE

To determine the optimal number of day 3 embryos to transfer in women >or=38 years by conducting an evidence-based evaluation.

DESIGN

Retrospective analysis of 2000-2004 national SART data.

SETTING

National writing group.

PATIENT(S)

A total of 36,103 day 3 embryo transfers in women >or=38 years undergoing their first assisted reproductive technology cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Logistic regression was used to model the probability of pregnancy, delivery, and multiple births (twin or high order) based on age- and cycle-specific parameters.

RESULT(S)

Pregnancy rates, delivery rates, and multiple rates increased up to transfer of three embryos in 38-year-olds and four in 39-year-olds; beyond this number, only multiple rates increased. In women >or=40 years, delivery rates and multiple rates climbed steadily with increasing numbers transferred. Multivariate analysis confirmed the statistically significant effect of age, number of oocytes retrieved, and embryo cryopreservation on delivery and multiple rates. Maximum FSH level was not an independent predictor by multivariate analysis. Use of intracytoplasmic sperm injection was associated with lowered delivery rate.

CONCLUSION(S)

No more than three or four embryos should be transferred in 38- and 39-year-olds, respectively, whereas up to five embryos could be transferred in >or=40-year-olds. Numbers of embryos to transfer should be adjusted according to number of oocytes retrieved and availability of excess embryos for cryopreservation.

A review and meta-analysis of prospective trials comparing different catheters used for embryo transfer

OBJECTIVE

To determine the relative efficacy of different types of embryo transfer (ET) catheters.

DESIGN

Systematic review and meta-analysis of prospective randomized, controlled trials comparing at least two different ET catheters.

SETTING

Infertility centers providing treatment with in vitro fertilization/embryo transfer (IVF-ET).

PATIENT(S)

Women undergoing ET.

INTERVENTION(S)

Embryo transfer with soft or hard catheters.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate.

RESULT(S)

A total of seven prospective trials were identified that compared soft (Cook or Wallace) catheters with hard (TDT, Frydman, Tomcat, Rocket) catheters. The meta-analysis demonstrated an increased chance of clinical pregnancy when soft ET catheters were used. The TDT catheter was compared against both soft catheters and other hard catheters, showing decreased chance of clinical pregnancy when the TDT catheter was used. Six more prospective trials were identified comparing the Cook and Wallace soft catheters, and the meta-analysis of these data showed no demonstrable difference in clinical pregnancy rates.

CONCLUSION(S)

An increased chance of clinical pregnancy is achieved when soft ET catheters are used. There appears to be little difference between the Cook and Wallace soft catheters.

Embryo transfer: factors involved in optimizing the success

PURPOSE OF REVIEW

Embryo transfer is arguably the most critical step in assisted reproduction. The purpose of this article is to review the different aspects of the procedure in the light of recent evidence.

RECENT FINDINGS

Randomized trials have shown that significantly higher pregnancy rates are obtained when embryo transfer is performed under ultrasound guidance, the embryos are deposited in the middle part of the uterine cavity, an atraumatic technique is used and when low-dose aspirin is routinely administered following the procedure. Blood in the catheter and leaving the embryos inside it for more than 120 s diminish the pregnancy rate significantly. Air in the catheter, immediate removal of the catheter, performing two transfers in the same cycle, prolonged bed rest, sexual intercourse after embryo transfer or the use of sildenafil do not affect the results. Based on currently available evidence, Cochrane reviews have concluded that the live birth rate is not increased by delaying embryo transfer from day two to three or to the blastocyst stage, and that single embryo transfer leads to lower live birth rates than the transfer of two embryos. The value of a mock transfer a few days before the actual procedure has been challenged as the position of the uterus may change. The effect of holding the cervix with a volsellum, routinely administering antibiotics and the superiority of one catheter over the others is still to be determined.

SUMMARY

Recent studies confirm the importance of the various aspects of embryo transfer. More randomized studies are needed to further evaluate them.

Factors affecting assisted reproductive technology (ART) pregnancy rates: a multivariate analysis

PURPOSE

To determine factors instrumental in achieving a clinical pregnancy in assisted reproductive technology (ART) patients.

METHODS

This study included 205 women undergoing their first ART cycle. Univariate and multivariate analyses were performed for patient demographics, in vitro production data, and factors associated with embryo transfer. Odds ratios (OR) were performed where appropriate.

RESULTS

Our analyses indicated that age (OR: 0.879), specific year in which the cycle was performed (OR: 2.959), and use of intracytoplasmic sperm injection (OR: 2.867) altered potential pregnancy rate. In addition, percent fertilization (OR: 1.028), number of embryos transferred (OR: 1.842), type of catheter used to transfer the embryos (OR: 0.377), presence of blood on the catheter (OR .414), and embryologist (OR: 2.338) also altered pregnancy rate.

CONCLUSIONS

Our data indicate patients' age, use of the Cook catheter, and presence of blood on the catheter reduce pregnancy rates. Performing ART in 1999, using ICSI, increasing fertilization rate, increasing number of embryos transferred (albeit less desirable when the chance of multiple gestation may occur), and transferring embryos via a particular embryologist, improve pregnancy rates.

Ultrasound-guided trial transfer may be beneficial in preparation for an IVF cycle

BACKGROUND

The objective of this study is to determine if ultrasound-guided trial transfer (UTT) in the office in preparation for an IVF cycle can be utilized as an alternative and/or adjunct to ultrasound-guided embryo transfer (UGET).

METHODS

Patients planning to undergo an IVF cycle at an academic centre were included. Each patient underwent an UTT in the office by the same practitioner. The difference in length (DL), if any, was measured from the perceived top of the uterine cavity (catheter tip) to the actual cavity apex as visualized by ultrasound.

RESULTS

Of the 64 patients enrolled, 19 patients (29.7%) had a measurable DL, of which 14 (21.9%) had a DL exists 0.5 cm, and nine (14.1%) had a DL exists 1.0 cm. Significant differences were noted between patients when comparing DL to previous pregnancy status and the total cavity depth (sounding depth + DL) (P < 0.05).

CONCLUSION

UTT in the office setting appears to be beneficial in preparation for an IVF cycle with embryo transfer.

Ongoing pregnancy rates in in vitro fertilization are not dependent on the physician performing the embryo transfer

OBJECTIVE

To analyze the influence of the factor of the physician performing the ET with a standardized procedure on the ongoing pregnancy rates in an IVF-ET program.

DESIGN

Prospective observational study.

SETTING

Tertiary university hospital.

PATIENT(S)

Subfertile women with an IVF indication.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy.

RESULT(S)

Six physicians performed 977 ETs. Ongoing pregnancy rates ranged from 19.1% to 29.0%, with an average rate of 23.1%. Logistic regression analysis revealed that physician is not a statistically significant variable. Differences between the pregnancy rates achieved by the physicians are within the limits of random variation.

CONCLUSION(S)

The probability of success in IVF is not dependent on the physician, provided the transfer procedure is standardized.

Ultrasound-guided embryo transfer and the accuracy of trial embryo transfer

BACKGROUND

Studies have suggested that ultrasound-guided embryo transfer (UG-ET) may improve the outcome in IVF; however, several factors may account for the improvement in pregnancy rate. This study examines the use of ultrasound to determine the accuracy of trial transfer (TT) in preparation for ET.

METHODS

Sixty-seven consecutive patients prospectively underwent UG-ET over a 2 month period. Total cavity length by US was compared with the length noted by TT. A difference of > or = 1 cm was considered significant. All embryos were placed within 1-2 cm of the fundus by US.

RESULTS

Twenty patients (29.9%) had a difference of > or = 1 cm and 13 patients (19.4%) had a difference of < or = 1.5 cm. Patients with a difference of > or = 1 or > or = 1.5 cm had a significantly greater depth at transfer (P < 0.001) and uterine cavity length (P < 0.001) when compared with patients without a difference. Clinical pregnancy, implantation, delivery and overall miscarriage rates did not differ between patients with a difference of > or = 1 or > or = 1.5 cm versus no difference. There were no ectopic pregnancies.

CONCLUSIONS

Nineteen percent of patients had a discrepancy of > or = 1.5 cm and approximately 30% had a difference of > or = 1 cm from TT at UG-ET, suggesting a benefit to UG-ET. A large prospective randomized trial comparing UG-ET with blind transfer is required to assess further if UG-ET should be used in all cases of ET.

Cannulation of a resistant internal os with the malleable outer sheath of a coaxial soft embryo transfer catheter does not affect in vitro fertilization–embryo transfer outcome

OBJECTIVE

To assess the impact of cannulation of a resistant cervical os with the outer malleable sheath of a double-lumen, soft ET catheter on IVF-ET outcomes.

DESIGN

Retrospective cohort study.

SETTING

University-based IVF center.

PATIENT(S)

One hundred forty-two patients undergoing 142 ETs.

INTERVENTION(S)

Trial ultrasound-guided ET at all transfers, leaving the malleable outer sheath in situ when the soft inner catheter could not negotiate the internal os.

MAIN OUTCOME MEASURE(S)

Implantation rate and clinical pregnancy rate.

RESULT(S)

In 102 ETs (71.8%), the soft inner sheath easily negotiated the internal os (group 1). Forty ETs (28.2%) required cannulation of resistant internal ora with the outer sheath of the trial catheter (group 2). Implantation rates (35% vs. 32% in groups 1 and 2, respectively) and clinical pregnancy rates (50% vs. 45%) were not significantly different between groups. Blood was present on the transfer catheter after ET more frequently in group 2 than in group 1 (55% vs. 15%); however, neither the implantation rate nor the clinical pregnancy rate were affected by the presence of blood.

CONCLUSION(S)

Cannulation of a resistant internal os by the malleable outer sheath and blood on the transfer catheter after ET do not have an adverse effect on implantation rate or clinical pregnancy rate.

An evidence-based evaluation of endometriosis-associated infertility

Although endometriosis is associated with infertility, a clear causal relationship has yet to be established, unless adhesive disease is found. Despite this indirect association, multiple theories have been promulgated and studies are currently underway to investigate theoretic pathogenetic mechanisms. The data regarding the treatment of endometriosis-associated infertility are limited and conflicting; however, some general preliminary conclusions can be drawn. It seems that, with early-stage disease, surgical treatment increases pregnancy rates. Using the US Preventive Services Task Force classification scheme, the evidence in support of this finding is of the highest quality, or level I. Surgical treatment for moderate and severe disease also confers benefit, although the evidence in support of this treatment is of lesser quality, level II-3 by the scheme. Medical treatment, particularly if it induces an anovulatory state, has no benefit and may delay fertility. This evidence is again of the highest quality, with a classification of level I. Although assisted reproductive technologies are of benefit regarding fertility for women with endometriosis, the IVF evidence is inconclusive, with both treatments being evaluated by at least one randomized, controlled trial conferring a level I classification to the evidence. It is unclear at this time whether endometriomas have an impact on IVF outcome. The evidence consists of only a few lower-quality studies, with a classification level of II-2. Despite the haziness of current insight into the treatment of endometriosis-associated infertility, well-designed clinical trials and basic mechanistic investigations are underway in many reproductive medicine centers. As the data from these scientific inquiries emerge, clinicians will have a clearer view of effective treatment regimens for endometriosis.

Impact of technical difficulties, choice of catheter, and the presence of blood on the success of embryo transfer--experience from a single provider

PURPOSE

To investigate the impact of technical difficulties, choice of catheter, and the presence of blood during embryo transfer on the results of in vitro fertilization and ICSI.

METHODS

A cohort of 784 consecutive cycles in 655 in vitro fertilization and ICSI patients were studied.

RESULTS

Negotiating the cervix, using the volsellum, presence of blood on the catheter wall or on the cervix did not affect the results. Changing the catheter and blood on the catheter tip reduced the pregnancy (P < 0.05 and P < 0.05) and implantation rates (P < 0.001 and P < 0.01). The Ultrasoft catheter produced higher pregnancy (P < 0.0005) and implantation rates (P < 0.01) compared to the more rigid Frydman catheter.

CONCLUSIONS

Negotiation of the cervix, the use of a volsellum, and the presence of blood on the catheter wall or on the cervix do not affect the results. Changing the catheter and blood on the catheter tip significantly diminish the pregnancy and implantation rates. Soft catheters perform better.

Ultrasound measurement of the uterocervical angle before embryo transfer: a prospective controlled study

BACKGROUND

The study aim was to determine whether moulding the embryo transfer catheter according to the uterocervical angle measured by ultrasound could improve pregnancy and implantation rates.

METHODS

Patients were alternately allocated to one of two groups. In the ultrasound-guided group (n = 320), the catheter was moulded according to the uterocervical angle measured by abdominal ultrasound. In controls (n = 320), embryo transfer was performed using the "clinical feel" method.

RESULTS

Moulding the embryo transfer catheter according to the uterocervical angle significantly increased clinical pregnancy [(OR = 1.57, 95% CI (1.08-2.27)] and implantation rates [(OR = 1.47, 95% CI (1.10-1.96)] compared with the "clinical feel" method. It also significantly reduced difficult transfers [(OR = 0.25, 95% CI (0.16-0.40)] and blood during transfers [OR = 0.71, 95% CI (0.50-0.99)]. Patients with large angles (>60 degrees ) had significantly lower pregnancy rates compared with those with no angle [OR = 0.36, 95% CI (0.16-0.52)].

CONCLUSIONS

Moulding the embryo transfer catheter according to the uterocervical angle measured by ultrasound increases clinical pregnancy and implantation rates and diminishes the incidence of difficult and bloody transfers.

A Wallace malleable stylet for difficult embryo transfer in an in vitro fertilization program: a case-control study

BACKGROUND

The aim of the study was to evaluate the impact of using a Wallace malleable stylet in combination with an Edwards-Wallace embryo replacement catheter in case of difficult embryo transfer (ET).

METHODS

A retrospective case-control study was used. The standard ET procedure at the clinic was to use a single tooth tenaculum, and a speculum to straighten the cervical canal prior to inserting the Edwards-Wallace embryo replacement catheter. In 205 of 2041 (10%) fresh ET difficulties were experienced during ET and a Wallace malleable stylet was used to place the outer catheter sheath correctly. This stylet transfer group was compared with a control transfer group of 410 ET performed just before and after each stylet transfer.

RESULTS

No differences in number of transferred embryos, cleavage stage, or embryo morphology score were found between the two groups. We found no differences in implantation rates (20.7 and 19.2% [95% confidence interval (CI) 0.8-1.5]) or delivery rates (29.3 and 25.4% [CI 0.8-1.8]) between the study and control group.

CONCLUSION

Using a Wallace malleable stylet in combination with an Edwards-Wallace embryo replacement catheter in case of difficult ET has no negative impact on implantation and delivery rates.

Endometriosis and assisted reproductive technologies: are outcomes affected?

The preponderance of recent data suggests that endometriosis does not adversely affect in-vitro fertilization pregnancy rates. However, many studies demonstrate impaired oocyte quality, decreased fertilization, and compromised implantation rates. Such findings give insight into the mechanisms by which endometriosis may impact on fertility, and provide clues as how to focus assisted reproductive technologies in order to overcome these deficiencies. Specifically, extended downregulation protocols, ample use of gonadotropins for ovarian stimulation, and conservative management of endometriomas have all been suggested as means to optimize in-vitro fertilization outcomes for women with endometriosis.