Ultrasound-guided soft catheter embryo transfers will improve pregnancy rates in in-vitro fertilization

Steps forward in embryo transfer technique: a retrospective study comparing direct versus afterload catheters at different time frames

PURPOSE

To assess whether embryo transfer (ET) technique can influence the clinical pregnancy rate (CPR) and its correlation with the embryo transfer difficulty.

DESIGN

This single center retrospective cohort analysis of fresh and frozen single blastocyst transfers performed between January 2016 and December 2021 included fresh and frozen single blastocyst transfers performed during the study timeframe. Direct technique was the only one used from January 2016 to September 2017. From September 2017 to March 2019, the choice between the two techniques was given by randomization, due to a clinical trial recruitment. From April 2019, only the afterload technique was used. Preimplantation genetic testing cycles and gamete donation procedures and cycles performed with external gametes or embryos were excluded. CPR was the primary outcome, while difficult transfer rate the secondary one. Univariate and multivariate logistic regressions were performed.

RESULTS

During the period, 8,189 transfers were performed. CPR of the afterload group resulted significantly higher compared to the direct group (44.69% versus 41.65%, OR 1.13, 95% CI 1.02-1.25, p = 0.017) and the rate of difficult transfers two-thirds lower (9.06% versus 26.85%, OR 0.27, 95% CI 0.24-0.31, p < 0.001).

CONCLUSION

Our study demonstrated that CPR is significantly affected by the ET technique. In particular, with the afterload protocol, both CPR and easy transfer rates increased.

TRIAL REGISTRATION

http://clinicaltrials.gov registration number: NCT05364528, retrospectively registered on 3rd of May 2022.

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.

Administration of oxytocin antagonist at the same time as using a Foley catheter with cotton swab before embryo transfer for cervical stenosis

Background

Embryo transfer without difficulty in a patient with cervical stenosis can be a great challenge for in vitro fertilization (IVF). We report a successful pregnancy following a frozen thawed embryo transfer after administration of an oxytocin antagonist at the same time as using a Foley catheter with cotton swab in a patient with refractory cervical stenosis.

Case presentation

A 40-year-old woman undergoing IVF. The patient’s previous embryo transfers were difficult. For every transfer, uterine manipulation was needed, force was required, and dilatation was necessary. A Foley catheter with a cotton swab was inserted into the cervical canal, atosiban was administered at the same time, and the Foley catheter was removed immediately before embryo transfer. A smooth transfer was performed without bleeding, force, uterine manipulation, or cervical dilator. The patient became pregnant and delivered by cesarean section at term.

Conclusion

This method is effective in performing atraumatic embryo transfer in patients with cervical stenosis.

Efficacy and Safety of gonadotropin-releasing hormone (GnRH) Agonists Triptorelin Acetate and Cetrorelix Acetate in Assisted Reproduction

Background

The aim of this study was to compare the efficacy and safety of 2 GnRH agonists – triptorelin acetate and cetrorelix acetate – in assisted reproduction.

Material/Methods

A total of 182 females who received in vitro fertilization and embryo transfer (IVF+ET) from March 2014 to July 2014 were involved, and their clinical data were retrospectively analyzed. Among them, 91 patients received treatment with short-acting triptorelin (group A) and another 91 patients were treated with cetrorelix acetate (group B). Fasting blood was extracted from each patient on the day of administration of human chorionic gonadotropin (hCG), and serum levels of luteinizing hormone (LH), estradiol (E2), and progesterone (P) were detected using chemiluminescence method. The number of oocytes, fertilization rate, cleavage rate, and number of obtained embryos were recorded and compared. Pregnancy outcomes and adverse events were observed and compared. Expression level of FSH receptor (FSHR) in endometrial tissues was measured by qRT-PCR.

Results

Serum level of E2 was significantly lower in group B than in group A (p<0.05). Indices, including the number of oocytes, fertilization rate and cleavage rate, number of obtained embryos, and pregnancy rate, were slightly better in group B than in group A, but no significant differences were found. The incidence of ovarian hyperstimulation syndrome (OHSS) was significant higher in group A than in group B (p<0.05). FSHR expression level was significantly lower in group B than in group A.

Conclusions

The effect of cetrorelix acetate is superior to that of short-acting triptorelin in assisted reproduction. Our most important finding is that cetrorelix acetate reduced the incidence of OHSS.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

SETTING

Tertiary Assisted Reproductive Technology (ART) center.

PATIENTS

All patients enrolled in the IVF program undergoing ET.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

Cleavage rate and clinical pregnancy rate.

RESULTS

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

CONCLUSION

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

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an assisted reproductive technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good-quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as more effective techniques of embryo transfer. This review evaluates the efficacy of ultrasound-guided embryo transfer (UGET) compared with 'clinical touch' (CTET), which is the traditional method of embryo transfer and relies on the clinician's tactile senses to judge when the transfer catheter is in the correct position.

OBJECTIVES

To determine whether ultrasound guidance compared with clinical touch improves pregnancy outcomes in women undergoing embryo transfer during ART cycles.

SEARCH METHODS

For the 2016 update of this review, we ran updated searches in the Cochrane Gynaecology and Fertility Group trials register (May 2015), the Cochrane Central Register of Controlled Trials (the Cochrane Library, May 2015), MEDLINE (2009 to May 2015), and EMBASE (2009 to May 2015). We also handsearched relevant conference proceedings: American Society for Reproductive Medicine (ASRM), European Society for Human Reproduction and Embryology (ESHRE), and International Federation of Gynecology and Obstetrics (FIGO). There were no language restrictions.

SELECTION CRITERIA

We included only randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials and extracted data from those selected. We calculated odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. No outcomes were reported using continuous data. We assessed the overall quality of the evidence for the main findings using the GRADE working group methods.

MAIN RESULTS

This systematic review now has 21 included studies (four of which we added in the 2016 update), two studies awaiting assessment, and 47 excluded studies. In total, data for meta-analyses were available in 21 trials (n = 6218 women), of which only four reported live births.UGET was associated with an increased chance of a live birth/ongoing pregnancy compared with CTET (OR 1.47, 95% CI 1.30 to 1.65; 13 trials; n = 5859 women; I(2) = 74%; low-quality evidence). Sensitivity analysis by including only trials with low risk of selection bias or by using a random-effects model did not alter the effect. We estimate that for women with a chance of a live birth/ongoing pregnancy of 23% using CTET, this would increase to between 28% and 33% using UGET. We considered the quality of the evidence using GRADE methodology to be low.UGET was associated with an increase in the chance of a clinical pregnancy (OR 1.31, 95% CI 1.17 to 1.45; 20 trials; n = 6711 women; I(2) = 42%; moderate-quality evidence). We identified no differences between groups for the incidence of adverse events including multiple pregnancy, ectopic pregnancy, or miscarriage. These events were relatively rare, and sample sizes limited the ability to detect such differences.

AUTHORS' CONCLUSIONS

The evidence suggests ultrasound guidance improves the chance of live birth/ongoing and clinical pregnancies compared with clinical touch, without increasing the chance of multiple pregnancy, ectopic pregnancy, or miscarriage. Methodological limitations included: only four studies reporting details of both computerised randomisation techniques and adequate allocation concealment, only four studies reported on the outcome of live birth, and none of the nine studies that reported on ongoing pregnancy reported on live birth, suggesting possible reporting bias. Adequate reporting of randomisation and allocation concealment will improve the quality of future studies. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Successful twin delivery following transmyometrial embryo transfer in a patient with a false uterine cavity

A successful pregnancy is the greatest goal for reproductive medicine. The probability that pregnancy occurs during a cycle of assisted reproduction is a function of multiple factors, of which embryo transfer is one of the most critical steps in these treatments. This article reports a case of successful pregnancy and twin delivery by transmyometrial embryo transfer after IVF in a woman with a neocavity parallel to the uterine cavity, which prevented the transfer of embryos to the correct place. The patient first went to another fertility centre where embryo transfer was impossible to perform because the cervix could not be canalized. Subsequently in this study clinic, after considering the difficulty of inserting a catheter into the endometrial cavity, a trial transfer was performed, which discovered a false route parallel to endometrial cavity. Following a first cycle in which conventional transcervical embryo transfer was performed, a transmyometrial embryo transfer was carried out and the patient became pregnant with twins. In cases where transcervical embryo transfer is very difficult or impossible to perform, the value of transmyometrial transfer is self-evident.

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

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

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.

Use of Versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilization-embryo transfer outcome: A case series

BACKGROUND

Smooth atraumatic embryo transfer is paramount for the success of in-vitro fertilization (IVF). In difficult cases, cervical canal manipulation may be required.

AIM

To see if surgical correction of the cervical canal or cervical canal refashioning could improve ease of embryo transfer.

SETTING

Private infertility and IVF hospital.

DESIGN

Prospective study.

MATERIALS AND METHODS

PATIENTS

11 women with failed 1-3 IVF cycles with history of extremely difficult embryo transfers (ETs) despite undergoing cervical dilatation in the cycle prior to IVF.

INTERVENTIONS

Operative hysteroscopy using Versapoint for refashioning of the cervical canal.

MAIN OUTCOME MEASURES

Ease of ET in the subsequent IVF cycle. Secondary outcome measure was to assess reproductive outcome.

RESULTS

Easy and atraumatic ET in the IVF cycle after procedure in 100% patients. PR was 46.5%.

CONCLUSIONS

Use of Versapoint for refashioning the cervical canal can improve the quality of ET and PR.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Quality 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.

Factors affecting pregnancy in IVF: age and duration of embryo transfer

The aim of this retrospective study was to investigate factors affecting clinical pregnancy rates, especially age and duration of embryo transfer, in IVF/intracytoplasmic sperm injection cycles (1313 embryo transfers). Overall clinical pregnancy rate was 30.0% (n=394). Clinical pregnancy rates were found to be 31.6% for the <44 s interval, 25.9% for the 45-59 s interval and 23.6% for the > or = 60 s interval (P=0.020). In the <35 year age group, clinical pregnancy rates were 35.1%, 29.9% and 30.6%, and in the > or = 35 year age group, they were 26.9%, 21.0% and 13.4% (P=0.013), respectively. According to logistic regression analyses, the odds of failed pregnancy increased by 1.61 times [95% confidence interval (CI) 1.07-2.41] for embryo transfer durations longer than 60 s and odds ratios of a failed pregnancy were 1.53 (95% CI 1.18-1.99) in the > or = 35 year age group, 1.49 (95% CI 1.05-2.12) for fewer than five oocytes and 3.38 (95% CI 2.10-5.43) for fewer than two transferred embryos. In conclusion, to increase the likelihood of a successful pregnancy in women over 35 years of age, the duration of embryo transfer must be kept below 60 s. The number of oocytes obtained and the number of transferred embryos also play a role in the success of pregnancy.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a more effective technique of embryo transfer. This review evaluates the effectiveness of ultrasound guided embryo transfer (UGET) compared with 'clinical touch' (CTET) the traditional method of embryo transfer.

OBJECTIVES

To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles.

SEARCH STRATEGY

Electronic databases were searched in November 2009. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched November 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), MEDLINE (1970-2009), EMBASE (1985-2009), BIO Extracts (1980-2009). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO).

SELECTION CRITERIA

Only randomised controlled trials were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected.

MAIN RESULTS

This update identified 59 potential trials of which 42 were excluded. Data for analysis was available in seventeen studies. One study reported live births and personal communication resulted in data relating to this outcome being obtained in two additional studies. There is no evidence of a significant difference in the outcome of live birth (OR 1.14 (95%CI0.93 to 1.39; P=0.02) although heterogeneity was high (64%) and the results should be interpreted with caution. Seven studies reported on ongoing pregnancies. The ongoing pregnancies per woman randomised associated with UGET (441/1254) was significantly higher than for clinical touch (350/1218) OR 1.38, 95%CI 1.16 to 1.64, P<0.0003). No statistically significant differences in the incidence of adverse events were identified between the comparison groups. These events are relatively rare and sample sizes limit the ability to detect such differences.

AUTHORS' CONCLUSIONS

The studies are limited by their quality with only two studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

The impact of body mass index on assisted reproduction

PURPOSE OF REVIEW

Obesity is a worldwide problem. The effect of obesity on the outcome of assisted reproductive techniques is quite controversial.

RECENT FINDINGS

Although there is not an absolute consensus based on evidence, obesity may lengthen the duration of ovulation induction, increase the gonadotrophin dose, decrease the peak estradiol levels, number of mature follicles and number of oocytes retrieved, and increase the cycle cancellation rate. Moreover, obesity may have a negative impact on oocyte and embryo quality. Thus, fertilization, embryo transfer, implantation and pregnancy rates have been usually found to be low in many studies. In addition, oocyte retrieval and embryo transfer procedures can be difficult due to obesity itself. Finally, miscarriage rate is found to be high. None of the studies related with obesity and assisted reproduction has been designed as a randomized controlled trial, yet. Definition of obesity, cause of infertility, protocols used for ovulation induction, starting dose for gonadotrophins, oocyte and embryo-grading systems are not standardized among the studies. Some confounding factors, such as polycystic ovary syndrome status and age, are not taken into consideration.

SUMMARY

Obesity has a negative impact on the outcomes of assisted reproductive techniques.

Advantages of 3-dimensional sonography in embryo transfer

OBJECTIVE

The purpose of this study was to investigate the advantages of 3-dimensional (3D) sonography in embryo transfer.

METHODS

With the use of 2-dimensional (2D) and 3D sonography to measure the transfer distance from the fundus (TDF), 319 patients were allocated into 4 groups according to the disparity between 2D and 3D images: group 1 showed disparity of less than 3 mm; group 2 showed disparity of 3 to 5 mm; group 3 showed disparity of 6 to 9 mm; and group 4 showed disparity of 10 mm or greater. The general characteristics and pregnancy outcomes were compared among the 4 groups.

RESULTS

For 140 patients, the TDF measured by 2D sonography was different from that measured by 3D sonography, with a positive to negative range of 3 to 13 mm. Compared with the first 3 groups, the clinical pregnancy and implantation rates were lowest in group 4 (7.7% versus 34.1%, 38.1%, and 40%; 3.6% versus 18.2%, 21.2%, and 22.2%; P < .05).

CONCLUSIONS

Compared with 2D sonography, uterine cavity and catheter placement may be better achieved with 3D sonography, which would improve the embryo transfer technique.

Uterine cavity shape and the best site for embryo transfer

OBJECTIVE

To determine the best site for embryo placement in uterine cavities of varying shapes.

METHOD

In this prospective investigation, 638 embryo transfers were allocated to two groups: for group 1 (n=558) embryos were transferred into uterine cavities of normal shape; for group 2 (n=80) embryos were transferred into uterine cavities of abnormal shape. The uterine cavity was divided into 3 equal regions: upper, middle, and lower. Pregnancy outcomes for placements in each region were compared within and between the 2 groups.

RESULTS

No significant differences were found in rates of pregnancy or implantation among the 3 regions in group 1. In contrast, the implantation rate in group 2 was highest when embryos were placed in the middle region of the uterine cavity: 28.8% compared with 6.8% and 8.3% for the upper and lower regions, respectively (P<0.05).

CONCLUSION

For the normal uterine cavity, pregnancy outcomes do not depend on embryo placement. However, for uterine anomalies, embryo placement in the middle region of the uterine cavity gave the best outcome.

Elevated body mass index (BMI) does not adversely affect in vitro fertilization outcome in young women

OBJECTIVE

To determine if elevated body mass index in young women with normal ovarian reserve was associated with poorer ovarian response, difficulty at embryo transfer, and lower clinical pregnancy rates.

MATERIALS AND METHODS

Retrospective study of 417 first, fresh in vitro fertilization cycles performed between October 2004 and December 2006. All women were under the age of 35 and had normal cycle day 3 follicle stimulating hormone and estradiol levels. Subjects were divided into groups by BMI: <18.5, 18.5-24.9, 25-29.9, > or = 30.

RESULTS

Cancellation rates, peak estradiol levels, and mean number of oocytes retrieved were similar in all groups. There was a trend toward increasing difficulty in visualizing the air bubble at time of embryo transfer and lower implantation rates at higher body mass indices. Clinical and ongoing pregnancy rates were similar among groups.

CONCLUSION

Obesity in young women does not adversely affect clinical pregnancy rates in patients treated with in vitro fertilization.

Prospective randomized comparison of Wallace and Labotect embryo transfer catheters

The aim of this study was to compare the clinical performance of Wallace and Labotect embryo transfer catheters in a single assisted reproduction centre. A total of 260 women undergoing embryo transfer were randomized between Wallace and Labotect catheters. When both catheters failed to negotiate the cervical canal, the transfer was accomplished with a stiff catheter. Intention to treat analysis revealed that Wallace and Labotect embryo transfer catheters yielded statistically similar clinical pregnancy (44.6 versus 34.6%), implantation (23.2 versus 18.9%) and ongoing pregnancy (38.5 versus 27.7%) rates. As treated analysis revealed clinical pregnancy rates of 42.5 versus 35.4%, implantation rates of 22.3 versus 20.6% and ongoing pregnancy rates of 36.8 versus 28.3% with Wallace and Labotect catheters respectively. Catheter change due to unsuccessful negotiation of the internal cervical os was significantly more frequently necessary when embryo transfer was first intended with the Wallace than the Labotect catheter (P < 0.001; 33 and 2% respectively). Although not being statistically significant, the observed differences may be regarded as clinically important and may reach statistical significance in larger trials. More trials are necessary before reaching a definitive conclusion regarding the performance of the Labotect embryo transfer catheter.

The impact of the depth of embryo replacement on IVF outcome

PURPOSE

To evaluate the effect of the depth of embryo transfer replacement on clinical pregnancy rate.

METHODS

Data from a total of 104 consecutive embryo transfers performed on 104 women aged 26-37 years were prospectively collected for this study. All patients underwent a standard down regulation protocol for ovarian stimulation. Oocytes retrieval were performed at 36 h after hCG administration. Embryo transfer took place at 48 h after insemination. The patients were matched in two groups according to the distance between the tip of the catheter and the uterine fundus at transfer (group A > 10 < 15 mm and group B < or = 10 mm). The same method of loading embryos into the embryo transfer catheter was used.

RESULTS

Clinical pregnancy rates varied significantly (p < or = 0.05) between the two groups: 27.7% in group A and 14% in group B. The number and quality of embryos transferred did not differ between the groups.

CONCLUSIONS

The results suggest that the depth of embryo replacement may be an important variable in embryo transfer technique.

Economics of flexible vs. rigid catheters for intrauterine insemination

A decision tree model was created to investigate pregnancy rates, as well as cost factors associated with rigid vs. flexible catheters. Although the flexible catheter costs more than the rigid catheter, it is associated with a higher pregnancy rate, which decreases costs of IUI treatment because fewer cycles are needed.

Comparison of pregnancy rates for two embryo-transfer catheters

OBJECTIVE

To compare two flexible catheters and determine whether pregnancy rates (PRs) differed.

DESIGN

Prospective, randomized pilot study.

SETTING

Tertiary-care infertility practice.

PATIENT(S)

The subjects for this study were 100 women undergoing assisted reproductive technology (ART) cycles between September 2003 and October 2005.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE

Clinical PR for Edwards-Wallace (Cooper Surgical, Shelton, CT) and Cook World (Cook Urological, Spencer, IN) embryo-transfer (ET) catheters.

RESULT(S)

The outcomes of pregnancy between the Edwards-Wallace and Cook World ET catheters were not significantly different. Use of the flare stimulation protocol resulted in a significantly lower PR compared to long luteal and antagonist protocols. No other variable affected PR.

CONCLUSION(S)

A 5% difference in PR was demonstrated between ET catheters; however, this study does not have the power to detect a significant difference in clinical PR between the two catheter groups. The pilot study demonstrates good design due to the lack of significant differences between the variables when stratifed by cather as well as pregnancy status. In a larger study, the flare protocol should be excluded.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to poor embryo quality, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a means of improving the technique of embryo transfer. This review evaluates the effectiveness of ultrasound (UGET) in comparison with 'clinical touch' embryo transfer (CTET) the traditional method of embryo transfer.

OBJECTIVES

:To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles.

SEARCH STRATEGY

All electronic databases were searched on 20 th August 2006. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched August 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2006), MEDLINE (1970-2006), EMBASE (1985-2006), BIO Extracts (1980-2006). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO).

SELECTION CRITERIA

Only randomised controlled trials were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected.

MAIN RESULTS

Thirteen out of fifteen identified studies were eligible for analysis. No study reported live births, however, personal communication resulted in data relating to this outcome being obtained in two of the studies. Six studies reported on ongoing pregnancies. The live birth/ ongoing pregnancies per woman randomised associated with UGET (452/1376) was significantly higher than for clinical touch (353/1338) OR 1.40, 95%CI 1.18 to 1.66, P<0.0001). This means, for example, that for a population of women with a 25% chance of pregnancy using clinical touch this would be increased to 32% (28% to 46%) by using UGET. There were no statistically significant differences in the incidence of adverse events between the two comparison groups with the exception of blood on the catheter.

AUTHORS' CONCLUSIONS

The studies are limited by their quality with only one of the thirteen studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasonographic-guided embryo transfer does not enhance pregnancy rates compared with embryo transfer based on previous uterine length measurement

OBJECTIVE

To compare pregnancy rates (PRs) after ultrasound-guided embryo transfer and embryo transfer based on ultrasonographic length measurement.

DESIGN

Prospective intervention group combined with retrospective control group.

SETTING

University fertility clinic.

PATIENT(S)

Patients undergoing IVF and intracytoplasmic sperm injection.

INTERVENTION(S)

Transabdominal ultrasonographic guidance at embryo transfer.

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates.

RESULT(S)

In 367 ultrasound-guided embryo transfers clinical PR, ongoing PR, and implantation rate were 35.1%, 31.1%, and 24.3%, respectively. In 363 embryo transfers based on previous ultrasonographic length measurement, the rates were 33.9%, 29.5%, and 24.2%, respectively. There were no statistical significant differences between the groups.

CONCLUSION(S)

Ultrasonographic guidance does not show any benefit in terms of PR and implantation rate compared to previous ultrasonographic length measurement, an other precise and atraumatic transfer technique.

Impact of hypnosis during embryo transfer on the outcome of in vitro fertilization-embryo transfer: a case-control study

OBJECTIVE

To investigate whether hypnosis during ET contributes to successful IVF/ET outcome.

DESIGN

Case-control clinical study.

SETTING

Academic Fertility and IVF Unit, Soroka Medical Center, Beer-Sheva, Israel.

PATIENT(S)

Infertile couples undergoing IVF.

INTERVENTION(S)

Ninety-eight IVF/ET cycles with hypnosis during the ET procedure were matched with 96 regular IVF/ET cycles.

MAIN OUTCOME MEASURES

Comparison of clinical pregnancy and implantation rates between the two groups.

RESULT(S)

We obtained 52 clinical pregnancies out of 98 cycles (53.1%) with an implantation rate of 28% among hypnosis IVF/ET cycles, and 29 out of 96 (30.2%) clinical pregnancies and an implantation rate of 14.4% in the control cycles. Our overall IVF program pregnancy rate for the same period was 32.1%. Logistic regression analysis was performed emphasizing the positive contribution of hypnosis to the IVF/ET conception rates.

CONCLUSION(S)

This study suggests that the use of hypnosis during ET may significantly improve the IVF/ET cycle outcome in terms of increased implantation and clinical pregnancy rates. Furthermore, it seems that the patients' attitude to the treatment was more favorable.

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.

Assessment of endocervical and endometrial damage inflicted by embryo transfer trial: a hysteroscopic evaluation

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.

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.

Predictive factors for embryo implantation potential

In spite of recent improvements in IVF, pregnancy rates have not increased significantly and one of the major problems remains the high multiple pregnancy rate. Better criteria are therefore necessary to establish the viability of a transferable embryo. Early prognosis of the developmental fate of the oocyte would help in selecting the best embryos to transfer, but non-invasive selection at the oocyte stage (extracytoplasmic and intracytoplasmic morphology) has proved to be of little prognostic value. Recently, it has been shown that follicular vascularization appears to be predictive of oocyte developmental fate, making it a good first-step approach for selection. Observation of pronuclei patterns at the zygote stage appears to offer an additional prognostic tool, correlating well with IVF outcome. Morphological evaluation of the embryo at days 2-3 remains the most used and valid method of selection, even though it is not sufficient to select embryos with the higher implantation potential. Blastocyst culture is another possible strategy for selecting the best embryos with reduced risk of aneuploidies, though not all major chromosomal aberrations are excluded by prolonged in-vitro culture. In summary, selecting the best embryo for transfer is a decision that should be based on choices made during the different stages of assisted reproductive technologies.

Three dimensional/four dimensional ultrasound-guided embryo transfer using the maximal implantation potential point

OBJECTIVE

To evaluate the use of maximal implantation potential (MIP) point in conjunction with a 3D/4D ultrasound in order to facilitate embryo transfers and potentially improve pregnancy rate.

DESIGN

Retrospective, observational study.

SETTING

IVF Center.

PATIENT(S)

Between October 1, 2002, and August 27, 2004, 1,222 patients who underwent 3D/4D-ultrasound guided embryo transfers.

INTERVENTION(S)

Ultrasound-guided embryo transfer using a 3D/4D ultrasound machine and the MIP point.

MAIN OUTCOME MEASURE(S)

Procedure feasibility with improved visibility.

RESULT(S)

Embryo transfers were performed at the MIP point and the pregnancy rate was 36.66% (average patient age, 37.6 years). Physicians reported improved visualization and a greater accuracy in the placement of embryos within the uterine cavity.

CONCLUSION(S)

The MIP point can be immediately identified and individualized for each patient. Embryo transfers at the MIP were associated with good implantation and pregnancy rates.

Soft versus firm embryo transfer catheters for assisted reproduction: a systematic review and meta-analysis*

BACKGROUND

The true impact of the embryo transfer catheter choice on an IVF programme has not been fully examined. We therefore decided to systematically review the evidence provided in the literature so that we may evaluate a single variable in relation to a successful transfer, the firmness of the embryo transfer catheter.

METHODS

An extensive computerized search was conducted for all relevant articles published as full text, or abstracts, and critically appraised. In addition, a hand search was undertaken to locate any further trials.

RESULTS

A total of 23 randomized controlled trials (RCT) evaluating the types of embryo transfer catheters were identified. Only ten of these trials, including 4141 embryo transfers, compared soft versus firm embryo catheters. Pooling of the results demonstrated a statistically significantly increased chance of clinical pregnancy following embryo transfer using the soft (643/2109) versus firm (488/2032) catheters [P = 0.01; odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.08-1.79]. When only the truly RCT were analysed, the results were again still in favour of using the soft embryo transfer catheters [soft (432/1403) versus firm (330/1402)], but with a greater significance (P < 0.00001; OR = 1.49, 95% CI = 1.26-1.77).

CONCLUSION

Using soft embryo transfer catheters for embryo transfer results in a significantly higher pregnancy rate as compared to firm catheters.

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.