Embryo transfer under ultrasound guidance improves pregnancy rates after in-vitro fertilization

Ultrasound Evaluation of Uterine Cavity Changes After Stimulation for In Vitro Fertilization

OBJECTIVES

Mock embryo transfer (ET) before in vitro fertilization (IVF) allows for the clinical determination of uterine cavity length (UCL) to optimize embryo placement during clinical ET. Most studies have shown that optimal pregnancy rates occur with clinical ET at a depth of 15 mm from the uterine fundus. In our study, we sought to determine the effect of ovarian stimulation and endometrial preparation on UCL using 2D transabdominal ultrasound.

METHODS

We performed a retrospective cohort study comparing documented 2D transabdominal ultrasound measurements of UCL at the time of mock ET and clinical ET. Statistical analyses were performed with SPSS v. 26 with paired sample t-test and significance determined with P < .05.

RESULTS

Seventy patients who underwent 91 IVF-ET cycles between 2015 and 2018 at our academic center met inclusion criteria. Patient's demographics include a median age of 34 (interquartile range [IQR]: 31, 37), gravida 1 (IQR: 0, 2), parity 0 (IQR: 0, 0), and body mass index 25.87 (IQR: 21.78, 30.01). There was a statistically significant increase in UCL by 11.9 mm after IVF stimulation (P < .001), compared to mock ET. Mean UCL at the time of mock ET was 7.66 cm (±0.98 cm) and at clinical ET was 8.85 cm (±0.98 cm).

CONCLUSIONS

The uterine cavity undergoes a significant length change during ovarian stimulation and endometrial preparation. These findings confirm the remarkable uterine plasticity in response to hormonal stimulation even before pregnancy ensues. These changes in UCL should be considered during ultrasound-guided clinical ET to ensure optimal embryo placement.

Sonographer-guided frozen embryo transfer vs ultrasound-assisted frozen embryo transfer - A randomised controlled study

BACKGROUND

The use of ultrasound to guide placement of the embryo during in vitro fertilisation (IVF) is important, but there are times where a good image cannot be obtained. Having a trained sonographer perform the ultrasound may therefore improve the success of embryo transfer.

AIM

To determine whether the routine use of a sonographer to guide embryo transfer is superior to standard care.

MATERIALS AND METHODS

Randomised, controlled, prospective clinical study in a private infertility clinic. There were 113 women aged <38 years undergoing frozen embryo transfer (donor egg/embryo excluded) who were randomised to sonographer-guided embryo transfer or standard care (the doctor performs an ultrasound prior to embryo transfer and the patient holds the ultrasound probe). The primary outcome was visualisation of the air bubble, and secondary outcomes were distance of the air bubble from the fundal endometrium, pregnancy rate (gestational sac on ultrasound at seven weeks) and live birth rate.

RESULTS

The bubble was visualised in 100% of embryo transfers with a sonographer compared to 83% in the ultrasound-assisted group, and this was statistically significant (P < 0.01). No statistically significant differences were found in terms of distance from the fundal endometrium or in pregnancy rate and live birth rate.

CONCLUSION

Sonographer-guided embryo transfer leads to statistically higher rates of visualisation of the air bubble compared to ultrasound-assisted transfer.

Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses

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.

Hysteroscopic endometrial peeling as a different approach to endometrial scratching. Case series report

STUDY QUESTION

Does hysteroscopic endometrial peeling improve reproductive outcomes in women with implantation failure?

DESIGN

In this case series, 66 women underwent an hysteroscopic endometrial peeling and subsequently, a single frozen embryo transfer.

RESULTS

After the exclusion of patients with intraoperative incidental findings, pregnancy was achieved in 63% (42/66) of the women who underwent hysteroscopic endometrial peeling and subsequently a single frozen embryo transfer, clinical pregnancy rate was observed in 57% (38/66) of the patients and, clinical pregnancy loss occurred in 10% (4/38).

CONCLUSION

this novel surgical technique seems to increase implantation as well as clinical pregnancy rates in women with repeated implantation failure. We can hypothesize that the controlled and subtle degree of endometrial injury generated by the peeling generates an inflammatory cascade that enhances implantation.

Effect of embryo transfer depth on IVF/ICSI outcomes: A randomized clinical trial

Background

Although there has been remarkable advancement in the field of assisted reproductive technology, implantation failure remains a significant issue in most infertile couples receiving these treatments. Embryo transfer is important in assisted reproductive technology and directly affects the implantation rates and pregnancy outcomes.

Objective

To assess the effect of two different distance embryo transfer sites from fundal endometrial surface on the outcomes of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

Materials and Methods

A total of 180 women who were candidate for IVF/ ICSI/ embryo transfer in Yazd Research and Clinical Center for Infertility were equally assigned to two groups based on the distance between the fundal endometrial surface and catheter tip to investigate implantation, chemical and clinical pregnancy (group A: 15 ± 5 mm and group B: 25 ± 5 mm, respectively).

Results

The subjects in the group B showed significantly higher implantation rate, chemical and clinical pregnancy rate compared to the group A (p = 0.03, 0.01, 0.04, respectively). The rate of ongoing pregnancy and miscarriage indicated no significant differences between groups (p = 0.21, 0.27, respectively).

Conclusion

In conclusion, our study showed that the depth of embryo replacement inside the uterine cavity at a distance of 25 ± 5 mm beneath fundal endometrial surface have better effects on the pregnancy outcomes of IVF/ICSI cycles and can be considered as an important factor to improve the success of IVF cycles.

Predictive factors influencing pregnancy rate in frozen embryo transfer

PURPOSE

To evaluate the outcomes of embryo transfer (ET) and to identify the parameters influencing pregnancy outcomes.

METHODS

This study included 938 ET cycles involving single frozen and thawed good-quality blastocyst (Gardner grade ≥3BB) between August 2017 and January 2018. The significance of several parameters including endometrial thickness, position of the transferred air bubble, self-evaluation score by physicians, and uterus direction at ET as predictors of clinical pregnancy was evaluated using univariate and multivariate analyses.

RESULTS

Among 938 ET cycles, 462 (49.3%) resulted in a clinical pregnancy. Endometrial thickness was positively associated with clinical pregnancy in a linear trend. Between the variable position of the transferred air bubble and clinical pregnancy rate showed a curvilinear relationship. Clinical pregnancy rate was higher in cases with good self-evaluation score, whereas there was no difference between groups with different uterus directions. Univariate analysis of predictive parameters identified endometrial thickness, self-evaluation score by physicians, and position of air bubbles as significant predictors of clinical pregnancy, of which endometrial thickness and position of air bubbles appeared to be independently related to clinical pregnancy.

CONCLUSION

Endometrial thickness and the position of transferred air bubbles influenced clinical pregnancy in ET cycles.

What is the clinical impact of the endometrial receptivity array in PGT-A and oocyte donation cycles?

PURPOSE

To evaluate the influence of the endometrial receptivity array (ERA) test on the implantation rate (IR) and pregnancy rate (PR) in patients with previous failed euploid embryo transfers (Euploid-ET) or oocyte donation embryo transfers (Donor-ET).

METHODS

Single-center retrospective study of patients with ≥ 1 previous failed Euploi-ET (n = 24) or ≥ 2 failed Donor-ET (n = 32) who underwent an ERA test and a post-ERA Euploid-ET/Donor-ET between 2012 and 2018. Controls were patients with ≥ 1 previously failed Euploid-ET (n = 119) or ≥ 2 failed Donor-ET (n = 158) who underwent Euploid-ET/Donor-ET during the same period without performing an ERA test. Only blastocyst stage embryos were included. IR/PR was compared between the post-ERA ET and the last ET in the control group.

RESULTS

There was no statistically significant difference regarding IR [55.6% (34.6-76.5%) vs. 65.0% (56.9-73.1%)] nor PR (58.3% vs.70.6%, p = 0.238) in the Euploid-ET ERA vs. Euploid-ET control groups. In the Donor-ET arm, both IR [26.8% (12.3-41.4%) vs. 57.2% (50.1-64.3%)] and PR (34.4% vs. 65.2%, p = 0.001) were significantly lower in the ERA group. Multivariate analysis confirmed that performing an ERA test did not influence the PR in the Euploid-ET arm and was associated with a diminished PR in the Donor-ET arm. In the ERA group, 41.1% patients were non-receptive (NR). No significant difference was found regarding IR/PR in NR vs. receptive patients in both Euploid-ET/Donor-ET arms.

CONCLUSIONS

In our sample, the performance of an ERA test did not improve pregnancy outcomes. Future prospective studies in larger samples are needed to confirm the role of the ERA test in Euploid-ET/Donor-ET.

Cumulative live birth rates and number of oocytes retrieved in women of advanced age. A single centre analysis including 4500 women ≥38 years old

STUDY QUESTION

Is there any relationship between the number of oocytes retrieved and cumulative live birth rates (CLBRs) in women of advanced age?

SUMMARY ANSWER

CLBRs increase with the number of oocytes retrieved in women of advanced reproductive age up to 41 years old, the added value is minimal in women more than 41 years and futile in women 44 years or older.

WHAT IS KNOWN ALREADY

CLBR is actually the most relevant outcome of IVF from patients' perspective. There are several studies that have analysed CLBR's but some of them have included several stimulation cycles, others have not included the frozen embryo transfers (FETs) in their analysis and none has focused on women of advanced reproductive age. We aimed to assess CLBR in women ≥38 years after a single stimulation cycle plus the subsequent frozen embryo transfers.

STUDY DESIGN, SIZE, DURATION

This is a retrospective analysis carried out in a University-affiliated tertiary centre between January 2000 and December 2013. Overall, 4570 infertile women aged ≥38 years who underwent their first cycle in our centre were included.

PARTICIPANT/MATERIALS, SETTING, METHODS

Patients were categorized in four age-groups: 38-39 years (G1 = 1875 cycles), 40-41 years (G2 = 1380 cycles), 42-43 years (G3 = 833 cycles) and ≥44 years (G4 = 482 cycles). CLBR's were evaluated by adding the pregnancies and live births achieved in the FET's to the ones obtained in the fresh cycle. In order to find out the actual effect of the number of oocytes retrieved in these patients, a predictive model of CLBR according to age and oocyte yield was built.

MAIN RESULTS AND THE ROLE OF CHANCE

CLBRs significantly decrease with increasing age among women ≥38 years of age, with the most prominent and clinically relevant decline observed at 42-43 years old, and clear evidence for futility in women aged ≥44 years (25.9% at 38-39 years, 16.4% at 40-41 years, 7% at 42-43 years and 1.2% from 44 years onwards). The higher the number of oocytes retrieved, the higher the CLBR; however, this is more evident up to 41 years old and no clear benefit is observed from 44 years and beyond.

LIMITATIONS, REASONS FOR CAUTION

Limitations are related to the retrospective nature of the study; however, no significant differences were observed in the treatment protocols used. Other potential limitations could be the fact that embryo cryopreservation was carried out with slow freezing in 80% of cases and that a small proportion of patients still have frozen embryos; nevertheless, we do not expect a relevant impact of these issues as slow freezing showed excellent results that did not differ significantly compared to vitrification and, on the other hand, the extra benefit coming from the FETs was very limited.

WIDER IMPLICATIONS OF THE FINDINGS

The number of oocytes retrieved is significantly associated with CLBR also in women of advanced reproductive age. However, the added benefit appears to be restricted mainly in women up to 41 years old. Women over 43 do not experience any benefit in CLBR irrespective of the number of oocytes retrieved, and thus should be discouraged from doing an IVF cycle with their own oocytes; for the other age-groups, recommendations should be given considering the age and the expected ovarian response.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NA.

Transmyometrial embryo transfer as a useful method to overcome difficult embryo transfers - a single-center retrospective study

OBJECTIVE

Pregnancy after an embryo transfer depends largely on embryo quality, endometrial receptivity, and the technique used in the embryo transfer. Embryo transfers have been reported as inevitably traumatic and difficult for 5-7% of patients in assisted reproduction treatment. In these cases, transmyometrial embryo transfer should be considered as a suitable method to overcome difficult embryo transfers. The aim of this study was to report our experience with this technique and analyze its causes, results and complications.

METHODS

Since 1993, 39 women (40 cycles of assisted reproductive technology treatment) were submitted to transmyometrial embryo transfers in our center. The procedures were carried out as described by the Towako group.

RESULTS

The enrolled female patients had a mean age of 34 years and a mean baseline FSH level of 6.89 IU/mL. The median number of retrieved oocytes was 7.50 and a mean of 2.63 embryos were transferred. Implantation rate was 9.5%. With respect to clinical results, pregnancy and miscarriage rates were 25% and 30%, respectively. Since there were two twin pregnancies, the live birth rate was 22.5% (9/40). No major complications were reported.

CONCLUSION

Transmyometrial embryo transfer can and should be an option in cases of difficult/impossible transcervical embryo transfer.

Difficult Embryo Transfer: A Systematic Review

We performed a systematic review on the clinical epidemiology and outcome of difficult embryo transfers (ETs) in infertility patients who present with difficult ET. We searched PubMed, ScienceDirect, and Elsevier journals from 1980 to June 2017. We aimed to determine the most successful method resulting in highest pregnancy rates (PRs) in patients with difficult ET. We identified 50 articles, in which 36 were reviewed and 15 were included. Analysis of the data collected showed that the majority of the difficult ETs were caused by cervical stenosis and the most common treatment was cervical dilation. We concluded that cervical dilation was effective at managing difficult ET. Hegar dilators used a minimum of 3 weeks before ET showed to have higher PR.

Intrauterine air impairs embryonic postimplantation development in mice

OBJECTIVE

Although most embryologists load air bubbles into the catheter along with embryos during embryo transfer, the effects of these air bubbles on embryo transfer success rate are not clear.

STUDY DESIGN

Air bubbles were nonsurgically injected into unilateral uterine horns of mice to demonstrate the negative effects of intrauterine air bubbles on embryonic development.

RESULTS

Our data showed that when air bubbles are nonsurgically injected into unilateral uterine horns of pregnant 4days mice the litter size is significantly decreased. Four days after the introduction of air, abnormal decidua and dead conceptuses were detected in the uterine horns receiving the air bubbles. In addition, intrauterine air also significantly impaired murine embryo transfer success rates, and induced an increase in endometrial capillary permeability and decidualization in mice on day 4 of pseudopregnancy. These results strongly indicated that the air bubbles loaded into embryo transfer catheters to bracket the embryo-containing medium may have negative effect on embryonic implantation and development.

CONCLUSIONS

Intrauterine air impaired murine embryonic postimplantation development, and this provided some clues for improving embryo transfer techniques in human.

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.

Is it justified to transfer two embryos in oocyte donation? A pilot randomized clinical trial

Multiple pregnancies involve high obstetric and perinatal risks. The aim of this study is to evaluate, in a pilot randomized control study, if the cumulative pregnancy and live birth rates of elective single embryo transfer (eSET) are comparable to the ones obtained with elective double embryo transfer (eDET). A total of 65 patients with at least two good quality embryos was randomized, 34 (52.3%) assigned to the eSET group and 31 (47.7%) to the eDET group. The cumulative pregnancy rates (eSET: 73.5% and eDET: 77.4%. RR: 0.95 95% CI: 0.72-1.25) and live birth rates (eSET: 58.8% and eDET: 61.3%. RR: 0.96 95% CI: 0.64-1.42) were similar in the two groups. The twin pregnancy rate in the fresh transfers of eDET group was 47.7% and 0% in the eSET group. The medical team decided to interrupt the study for reasons related to risks associated with elevated twin pregnancy rate, leaving low numbers of patients within the study as a result. When considering cumulative success rates, eSET and eDET are similar in terms of efficacy. However, eDET involves an increased and unacceptable twin pregnancy rate. The only prevention strategy is single embryo transfer.

Ultrasound guidance during embryo transfer: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To summarize the current evidence on the effect of using ultrasound (US) guidance during embryo transfer (ET).

METHODS

In this systematic review, we included randomized controlled trials examining the effect of the use of US guidance during ET; data from studies using the same catheter type in study arms were not pooled with the results from studies that used different catheter types.

RESULTS

Twenty-one studies were included in the quantitative analysis: 18 compared 'US guidance' with 'clinical touch', of which one was subsequently excluded from the quantitative meta-analysis owing to a lack of available data, three studies compared transvaginal US guidance with transabdominal US guidance, and one study compared 'hysterosonometry before ET' with US guidance. Comparison of the use of US guidance with clinical touch, in studies that used the same catheter type in the study arms, indicated a benefit of using US guidance during ET on the rates of live birth (relative risk (RR), 1.48 (95% CI, 1.16-1.87)), based on two studies involving 888 women with moderate-quality evidence, and on the rates of clinical pregnancy (RR, 1.32 (95% CI, 1.18-1.46)), based on 13 studies involving 3641 women with high-quality evidence. However, when comparing the use of US guidance with clinical touch in studies that used different catheter types, the results suggest that using US guidance during ET has no effect on the rates of reproductive outcome: live birth (RR, 0.99 (95% CI, 0.83-1.19)), based on one study involving 1649 women with moderate-quality evidence; clinical pregnancy (RR, 1.04 (95% CI, 0.89-1.21)), based on five studies involving 2949 women with moderate-quality evidence. The estimates for the rate of miscarriage and for the other identified comparisons were imprecise.

CONCLUSIONS

The available evidence suggests that there is a benefit of using US guidance during ET. However, both US-guided transfer and clinical touch should be considered acceptable, as the benefit of US is not large and should be balanced against the increased cost and need to change the catheter type. More studies are required before conclusions can be drawn regarding the effect of other techniques on reproductive outcome.

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.

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.

Triggering ovulation with 250 μg or 500 μg of r-hCG in oocyte donors treated with antagonist protocol has no effect on the number of mature oocytes retrieved: a randomized clinical trial

The aim of this study is to compare two r-hCG doses to trigger ovulation (250 μg vs. 500 μg of r-hCG) in an oocyte donation program. A prospective, randomized study was conducted in 118 oocyte donors. Group DI received 250 μg and Group DII received 500 μg of r-hCG. Both the groups were homogeneous. No significant differences were found in the total dose of gonadotropins, duration of the treatment, total number of oocytes, or Metaphase II (MII)oocytes. The pregnancy rate per embryo transfer in the corresponding recipients was similar for both the groups (58.2% for DII recipients and 56.1% for DI recipients). Mild hyperstimulation was observed in 17 donors in Group DI (29%) and in 23 donors in Group DII (39%). No cases of severe ovarian hyperstimulation syndrome (SOHSS) were observed. In conclusion, a double dose of r-hCG in oocyte donors to trigger ovulation after stimulation with r-FSH and antagonist does not translate into a higher number of MII oocytes retrieved or into higher pregnancy rates among recipients. Our results confirm that the optimal dose to induce the final oocyte maturation with r-hCG is 250 μg, and that a higher dose does not add any benefit.

Effect of air bubble localization after transfer on embryo transfer outcomes

OBJECTIVES

Our study aimed to provide information about the effects of air bubble localization after transfer on embryo transfer outcomes.

STUDY DESIGN

Retrospective analysis of 7489 ultrasound-guided embryo transfers. Group 1 included 6631 embryo transfers in which no movement of the air bubbles was observed after transfer. Group 2 consisted of 407 embryo transfers in which the air bubbles moved towards the uterine fundus spontaneously, a little time after transfer. Group 3 included 370 embryo transfers in which the air bubbles moved towards the uterine fundus with ejection, immediately after transfer. Group 4 consisted of 81 embryo transfers in which the air bubbles moved towards the cervical canal.

RESULTS

The four patient groups were different from one another with respect to positive pregnancy tests. Post hoc test revealed that this difference was between group 4 and other groups.

CONCLUSIONS

An initial finding of our study was significantly decreased positive pregnancy test rates and clinical pregnancy rates with air bubbles moving towards the cervical canal after transfer. Although air bubbles moving towards the uterine fundus with ejection were associated with higher pregnancy rates, higher miscarriage rates and similar live birth rates were observed compared to air bubbles remaining stable after transfer.

[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.

Poor prognosis for ovarian response to stimulation: results of a randomised trial comparing the flare-up GnRH agonist protocol vs. the antagonist protocol

OBJECTIVE

To determine the efficacy of the flare-up agonist and the antagonist protocols in patients with poor prognosis for ovarian response.

METHODS

A randomised trial was conducted on two hundred and twenty-one women considered as having poor prognosis for ovarian response to stimulation, based on previous cycles or clinical criteria. All women were prospectively randomised into two groups of treatment (flare-up group and antagonist group) by computer-assisted randomisation in a 1:1 ratio. The main outcome measure was clinical pregnancy rate.

RESULTS

Groups were homogeneous in age and baseline characteristics. Duration of stimulation, gonadotropin consumption, number of oocytes retrieved and number and quality of embryos transferred did not differ significantly between the groups. E(2) level the day of hCG administration was significantly higher in the flare-up group. Pregnancy rates per started cycle were 15% in the flare-up group and 14.1% in the antagonist group. Cancellation rates were 12.5% in the flare-up group and 16.3% in the antagonist group. None of these differences reached statistical significance.

CONCLUSIONS

No statistically significant differences were observed between the two protocols regarding clinical pregnancy rates. In patients with poor prognosis for ovarian response, the flare-up agonist and the antagonist protocols were comparable regarding clinical pregnancy rates.

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 position of transferred air bubbles after embryo transfer is related to pregnancy rate

OBJECTIVE

The possibility to visualize the transfer air bubbles is one of the main benefits of ultrasonographic-guided embryo transfer. The objective of this study was to analyze the relation between the position of the air bubbles and pregnancy rates.

DESIGN

Prospective data-analysis.

SETTING

University fertility clinic.

PATIENT(S)

IVF and intracytoplasmic sperm injection patients.

INTERVENTION(S)

Transabdominal ultrasonographic guidance at embryo transfer.

MAIN OUTCOME MEASURE(S)

Pregnancy rate, length endometrial plate, distance catheter to fundus, distance air bubbles to fundus.

RESULT(S)

Analysis of 367 consecutive ultrasonographic-guided embryo transfers following IVF or intracytoplasmic sperm injection treatment. Both absolute and relative position of the air bubbles were significantly closer to the fundus in patients who became pregnant compared with patients who did not become pregnant. When the relative position of the air bubbles was in the fundal half of the endometrial plate pregnancy rates were significantly higher compared with the lower half of the endometrial plate, 43.0% and 24.4%, respectively, P=.002. Multiple regression analysis revealed the relative position as an independently associated determinant for pregnancy.

CONCLUSION(S)

The position of the air bubbles after embryo transfer is related to pregnancy rate; the highest pregnancy rates are found when the air bubbles end up closer to the fundus.

Air bubble migration is a random event post embryo transfer

INTRODUCTION

Air bubble location following embryo transfer (ET) is the presumable placement spot of embryos. The purpose of this study was to document endometrial air bubble position and migration following embryo transfer.

DESIGN

Multicenter prospective case study.

MATERIALS AND METHODS

Eighty-eight embryo transfers were performed under abdominal ultrasound guidance in two countries by two authors. A single or double air bubble was loaded with the embryos using a soft, coaxial, end opened catheters. The embryos were slowly injected 10-20 mm from the fundus. Air bubble position was recorded immediately, 30 minutes later and when the patient stood up.

RESULTS

Bubble marker location analysis revealed a random distribution without visible gravity effect when the patients stood up. The bubble markers demonstrated splitting, moving in all directions and dispersion.

CONCLUSION

Air bubbles move and split frequently post ET with the patient in the horizontal position, suggestive of active uterine contractions. Bubble migration analysis supports a rather random movement of the bubbles and possibly the embryos. Standing up changed somewhat bubble configuration and distribution in the uterine cavity. Gravity related bubble motion was uncommon, suggesting that horizontal rest post ET may not be necessary. This report challenges the common belief that a very accurate ultrasound guided embryo placement is mandatory. The very random bubble movement observed in this two-center study suggests that a large "window" of embryo placement maybe present.

Uterine Position Change Between Mock and Real Embryo Transfers

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The influence of abdominal ultrasound-guided embryo transfer on pregnancy rate: a preliminary report

To determine whether the use of abdominal ultrasound-guided embryo transfer improves the clinical pregnancy rate in patients undergoing in vitro fertilization, 50 fresh cycles with day 3 embryo transfer were studied; 27 patients were randomized to ultrasound-guided transfers, and 23 patients were randomized to clinical touch transfers. Although the clinical pregnancy rate was not statistically different (18.5% in the ultrasound-guided group vs. 17.4% in the clinical touch group), the use of abdominal ultrasound during the embryo transfer procedure provided a greater degree of confidence and satisfaction to both patients and physicians.

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.

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.

Is what we clearly see really so obvious? Ultrasonography and transcervical embryo transfer—a review

OBJECTIVE

To critically review the role of ultrasound-guided embryo transfer (ET) and its influence on the outcome of in vitro fertilization (IVF).

DESIGN

Medline review of published manuscripts.

RESULT(S)

Studies evaluating the role of ultrasound-assisted ET have had mixed results, and although meta-analysis of prospective trials suggests an improvement in outcome, limitations in study design may overstate the effect of ultrasonography. Other ET techniques may eliminate the advantages provided by ultrasonography, limiting its benefit to specific clinical scenarios. However, because no trial has demonstrated an adverse effect and because cases that may benefit from its use often cannot be predicted reliably, the routine application of ultrasonography can be justified.

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.

A prospective trial comparing oocyte donor ovarian response and recipient pregnancy rates between suppression with gonadotrophin-releasing hormone agonist (GnRHa) alone and dual suppression with a contraceptive vaginal ring and GnRH

BACKGROUND

Contraceptive treatment before gonadotrophin-releasing hormone agonist administration presents advantages in women with a tendency to hyper-response and simplifies donor-recipient treatment synchronization. This study compares response to gonadotrophin stimulation under hypophyseal suppression in oocyte donors with or without vaginal contraceptive pretreatment.

METHODS

One hundred and ninety oocyte donors were recruited in a single centre and prospectively assigned to one of two treatment groups, according to the day of the week menstruation initiated: Group VC-, no prior vaginal contraceptive and Group VC+, prior vaginal contraceptive.

RESULTS

VC+ patients presented a significantly higher cancellation rate, lower plasma estradiol levels and fewer follicles >12 mm on the day of hCG, versus the VC- group. Number of oocytes recovered was significantly lower in the VC+ group. All the cases of severe ovarian hyperstimulation syndrome (SOHSS) were in the VC- group. Pregnancy rates by embryo transfer to synchronic recipients were similar between VC+ and VC- (59.5 versus 57.9%, respectively).

CONCLUSIONS

Vaginal contraceptive pretreatment resulted in a higher ovarian suppression, whereas SOHSS rate was lower than in donors who did not receive pretreatment. There were no differences in pregnancy rates between the two groups of synchronic oocyte recipients.