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Mizrachi Y, McQueen DB. Embryo transfer success: It is in our hands. Fertil Steril 2022; 118:815-819. [PMID: 36192230 DOI: 10.1016/j.fertnstert.2022.08.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Abstract
Embryo transfer (ET) is considered as a critical step in the process of in vitro fertilization. Interestingly, studies have consistently shown significant outcome differences between physicians. Although the outcome of ET is not related to the physician's experience and specifically not different between fellows and attending physicians, certain techniques have been found to affect the success rate. This review summarizes the existing evidence regarding the impact of the individual physician performing ET and the techniques used.
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Affiliation(s)
- Yossi Mizrachi
- Reproductive Services Unit, The Royal Women's Hospital, and University of Melbourne, Victoria, Australia
| | - Dana B McQueen
- Reproductive Medicine Associates, San Francisco, California.
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Tyler B, Walford H, Tamblyn J, Keay SD, Mavrelos D, Yasmin E, Al Wattar BH. Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses. Hum Reprod Update 2022; 28:480-500. [PMID: 35325124 PMCID: PMC9631462 DOI: 10.1093/humupd/dmac009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists. OBJECTIVE AND RATIONALE We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes. SEARCH METHODS We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses. OUTCOMES Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs. WIDER IMPLICATIONS Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.
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Affiliation(s)
- Bede Tyler
- UCL Institute for Women's Health, University College London, London, UK
| | - Hugo Walford
- UCL Institute for Women's Health, University College London, London, UK
| | - Jennifer Tamblyn
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
| | - Stephen D Keay
- Centre for Reproductive Medicine, University Hospital of Coventry & Warwickshire, Coventry, UK
| | - Dimitrios Mavrelos
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Ephia Yasmin
- UCL Institute for Women's Health, University College London, London, UK,Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK
| | - Bassel H Al Wattar
- Correspondence address. Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London, UK, WC1E 6DB. E-mail:
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Sallam HN, Gelbaya TA, Rosas IM, Anagnostopoulou C, Sallam N, Agarwal A. Clinical aspects of oocyte retrieval and embryo transfer. Tips and tricks for the novice and experts. Panminerva Med 2022; 64:185-199. [PMID: 35179015 DOI: 10.23736/s0031-0808.22.04679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oocyte retrieval (ovum pick-up) and embryo transfer (ET) are essential steps in IVF and ICSI and over the years, the two procedures were developed in order to improve the clinical outcome. Many suggestions were proposed and applied before, during and after oocyte retrieval such as timing of HCG trigger, pre-operative pelvic scan, vaginal cleansing, type of anesthesia, type and gauge of aspiration needles, aspiration pressure, follicle flushing, and the need for prophylactic antibiotics. Similarly, many steps were suggested and implemented before, during and after ET including patient's position, type of anesthesia/analgesia, dummy (mock) ET, ultrasound-guidance, HCG injection in the uterine cavity, use of relaxing agents, full bladder, removal of the cervical mucus, flushing the cervix with culture medium, type of ET catheter, embryo loading techniques, site of embryo deposition, the use of adherence compounds, as well as bed rest after ET. Complications were also reported with oocyte retrieval and ET. The aim of this review is to evaluate the current practice of these two procedures in the light of available evidence.
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Affiliation(s)
- Hassan N Sallam
- Department of Obsterics and Gynaecology, Alexandria University Faculty of Medicine, Alexandria, Egypt -
| | - Tarek A Gelbaya
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, UK
| | - Israel M Rosas
- Citmer Reproductive Medicine, IVF LAB, Mexico City, Mexico
| | | | - Nooman Sallam
- Department of Obstetrics and Gynaecology, Guy's and St Thomas' NHS Trust, London, UK
| | - Ashok Agarwal
- Andrology Center and American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Gurbuz AS, Yildiz Y. Does rotation during catheter withdrawal in embryo transfer increase pregnancy rates? J Chin Med Assoc 2021; 84:1135-1138. [PMID: 34698688 DOI: 10.1097/jcma.0000000000000645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The aim of this study was to determine whether there is a difference in pregnancy rates between groups that we removed directly and removed by rotating the embryo transfer catheter 360°. METHODS The study group consisted of 552 patients who were withdrawn by 360° rotation and 797 patients who were withdrawn without catheter rotation. All patients underwent one or two fresh ETs on day 3 or 5. Groups were compared in terms of cycle characteristics and clinical pregnancy rates. RESULTS There were no significant differences in demographic and clinical characteristics of both groups, such as age, body mass index (BMI), duration of infertility, causes of infertility, and basal hormone levels. Clinicals pregnancy rate, in the study group, 48% (265/552) and in the control group, 50.8% (405/797) were similar in both groups. When the implantation rate and miscarriage rate were examined, both groups were found to be similar. CONCLUSION It was found that 360° rotation while pulling catheter during embryo transfer had no effect on pregnancy and clinical pregnancy.
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Affiliation(s)
- Ali Sami Gurbuz
- Department of Obstetrics and Gynecology KTO Karatay University Medical Faculty Konya, Turkey
- Novafertil IVF Center Konya, Turkey
| | - Yunus Yildiz
- Department of Obstetrics and Gynecology ASV Life Hospital Antalya, Turkey
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Nancarrow L, Tempest N, Drakeley AJ, Homburg R, Russell R, Hapangama DK. National Survey Highlights the Urgent Need for Standardisation of Embryo Transfer Techniques in the UK. J Clin Med 2021; 10:2839. [PMID: 34198995 PMCID: PMC8267796 DOI: 10.3390/jcm10132839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/31/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
Embryo transfer (ET) is one of the vital steps in the in vitro fertilisation (IVF) process, yet there is wide variation in ET technique throughout the UK, without a nationally approved standardised approach. The aim of this study was to gain contemporaneous information regarding the current clinical ET practice in the UK. METHOD A 38-question electronic survey was distributed to the 79 UK Human Fertilisation and Embryology Authority (HFEA) registered clinics performing ETs. RESULTS In total, 59% (47/79) of units responded, 83% (39/47) performing ultrasound-guided transfers, with 42% (20/47) of units using a tenaculum; 22% (10/45) would proceed with transfer regardless of fluid in the endometrial cavity. In 91% (43/47) of units, embryos were deposited in the upper/middle portion of the uterine cavity, but interpretation of this area ranged from 0.5 to >2 cm from the fundus, with 68% (32/47) allowing patients to mobilise immediately after transfer. In 60% (27/45) of clinics, success rates were based on clinical pregnancy rates (CPR). CONCLUSION Within the UK there is a wide range of variability in ET techniques, with >70% of discordance in survey-responses between clinics. Whilst there are areas of good practice, some disadvantageous techniques continue to persist. This survey emphasises the importance of developing a standardised, evidence-based approach to improve ET success rates.
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Affiliation(s)
- Lewis Nancarrow
- Centre for Women’s Health Research, Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool L8 7SS, UK; (N.T.); (D.K.H.)
- Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool L8 7SS, UK; (A.J.D.); (R.R.)
| | - Nicola Tempest
- Centre for Women’s Health Research, Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool L8 7SS, UK; (N.T.); (D.K.H.)
- Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool L8 7SS, UK; (A.J.D.); (R.R.)
- Liverpool Women’s NHS Foundation Trust, Liverpool Health Partners, Liverpool L8 7SS, UK
| | - Andrew J. Drakeley
- Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool L8 7SS, UK; (A.J.D.); (R.R.)
| | - Roy Homburg
- Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London E9 6SR, UK;
| | - Richard Russell
- Hewitt Centre for Reproductive Medicine, Liverpool Women’s NHS Foundation Trust, Liverpool L8 7SS, UK; (A.J.D.); (R.R.)
| | - Dharani K. Hapangama
- Centre for Women’s Health Research, Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool L8 7SS, UK; (N.T.); (D.K.H.)
- Liverpool Women’s NHS Foundation Trust, Liverpool Health Partners, Liverpool L8 7SS, UK
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Alvarez M, Martínez F, Bourroul FM, Polyzos NP, Solé M, Parriego M, Rodríguez I, Barri PN, Coroleu B. Effect of embryo transfer difficulty on live birth rates studied in vitrified–warmed euploid blastocyst transfers. Reprod Biomed Online 2019; 39:940-946. [DOI: 10.1016/j.rbmo.2019.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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Saravelos SH, Li TC. Embryo transfer techniques. Best Pract Res Clin Obstet Gynaecol 2019; 59:77-88. [PMID: 30711373 DOI: 10.1016/j.bpobgyn.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Embryo transfer is the final and rate-limiting step of the assisted reproductive technique. Few advances have occurred in the last few decades with regard to this procedure. Studies conducted thus far have focused on factors and interventions taking place before, during and after this procedure. These factors are highly varied and range from methods to improve the psychological state of the patients to methods aimed at reducing uterine contractility and methods aimed at optimising the precise transfer of the embryo. The key question is which factors and interventions have thus far been proven to increase pregnancy rates and live birth rates. This paper aims to review the evidence relating to embryo transfer techniques in a systematic manner with a view to provide practical recommendations to practitioners involved in the procedure.
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Affiliation(s)
| | - Tin-Chiu Li
- Assisted Reproductive Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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Performing the embryo transfer: a guideline. Fertil Steril 2017; 107:882-896. [DOI: 10.1016/j.fertnstert.2017.01.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 11/17/2022]
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9
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Kava-Braverman A, Martínez F, Rodríguez I, Álvarez M, Barri PN, Coroleu B. What is a difficult transfer? Analysis of 7,714 embryo transfers: the impact of maneuvers during embryo transfers on pregnancy rate and a proposal of objective assessment. Fertil Steril 2017; 107:657-663.e1. [DOI: 10.1016/j.fertnstert.2016.11.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/28/2016] [Accepted: 11/21/2016] [Indexed: 12/01/2022]
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10
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Schoolcraft WB. Importance of embryo transfer technique in maximizing assisted reproductive outcomes. Fertil Steril 2016; 105:855-60. [DOI: 10.1016/j.fertnstert.2016.02.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 02/08/2016] [Accepted: 02/12/2016] [Indexed: 11/26/2022]
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Brown J, Buckingham K, Buckett W, Abou-Setta AM. Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women. Cochrane Database Syst Rev 2016; 3:CD006107. [PMID: 26984325 DOI: 10.1002/14651858.cd006107.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Julie Brown
- Liggins Institute, The University of Auckland, Park Rd, Grafton, Auckland, New Zealand, 1142
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Saravelos SH, Wong AWY, Kong GWS, Huang J, Klitzman R, Li TC. Pain during embryo transfer is independently associated with clinical pregnancy in fresh/frozen assisted reproductive technology cycles. J Obstet Gynaecol Res 2016; 42:684-93. [DOI: 10.1111/jog.12962] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/14/2015] [Accepted: 01/07/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Sotirios H. Saravelos
- Assisted Reproductive Technology Unit; Prince of Wales Hospital, Chinese University of Hong Kong; Shatin New Territories Hong Kong
| | - Alice WY. Wong
- Assisted Reproductive Technology Unit; Prince of Wales Hospital, Chinese University of Hong Kong; Shatin New Territories Hong Kong
| | - Grace WS. Kong
- Assisted Reproductive Technology Unit; Prince of Wales Hospital, Chinese University of Hong Kong; Shatin New Territories Hong Kong
| | - Jin Huang
- Assisted Reproductive Technology Unit; Prince of Wales Hospital, Chinese University of Hong Kong; Shatin New Territories Hong Kong
| | - Robert Klitzman
- Mailman School of Public Health; Columbia University Medical Centre; New York USA
| | - Tin-Chiu Li
- Assisted Reproductive Technology Unit; Prince of Wales Hospital, Chinese University of Hong Kong; Shatin New Territories Hong Kong
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Abstract
BACKGROUND Meta-analysis revealed that embryo placement 20 mm from the fundal endometrial surface resulted in higher pregnancy rate, ongoing pregnancy rate, and live birth rate compared with placement 10 mm from the fundal endometrial surface. Pregnancy and implantation rates according to relative position were higher when the catheter tip was positioned close to the middle of the endometrial cavity. The aim of the current study is to evaluate differences in implantation and pregnancy rates if the site of embryo transfer is 2 cm distance from the fundal endometrium (DFE) compared to the midpoint of the endometrial cavity length (ECL). METHODS Patients were randomized to one of two groups: in group A (n = 98, 98 IVF-ET cycles), the embryo transfer catheter tip was positioned 2 cm DFE, while that in group B (n = 97, 97 IVF-ET cycles) was positioned at the midpoint of the ECL. We compared pregnancy outcomes of implantation rate, chemical pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, ectopic pregnancy rate, and miscarriage rate in the two groups. RESULTS Analysis of implantation rate (19.5 ± 27.7 vs. 21.7 ± 32.6; p = 0.6), chemical pregnancy rate (51 % vs. 50.5 %; p = 0.94), clinical pregnancy rate (35.7 % vs. 38.1 %; p = 0.73), ongoing pregnancy rate (31.6 % vs. 30.9 %; p = 0.92), ectopic pregnancy rate (8.6 % vs. 2.7 %; p = 0.35), and miscarriage rate (11.4 % vs. 16.2 %; 0.74) revealed comparable results for both groups. CONCLUSIONS Implantation and pregnancy rates were not influenced by the site of the ET catheter tip being 2 cm DFE compared to at the midpoint of the ECL. ISRCTN ISRCTN15972342.
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Affiliation(s)
- Hwang Kwon
- Department of Obstetrics and Gynecology, CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
- College of Medicine, CHA University and CHA Fertility Center of Bundang CHA General Hospital, 351 Yatap-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-712, Korea.
| | - Dong-Hee Choi
- Department of Obstetrics and Gynecology, CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
| | - Eun-Kyung Kim
- CHA Fertility Center of Bundang CHA General Hospital, CHA University, Seongnam, Korea.
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Abstract
Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.
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Mains L, Van Voorhis BJ. Optimizing the technique of embryo transfer. Fertil Steril 2010; 94:785-90. [DOI: 10.1016/j.fertnstert.2010.03.030] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 03/09/2010] [Indexed: 11/17/2022]
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Madani T, Ashrafi M, Jahangiri N, Abadi AB, Lankarani N. Improvement of pregnancy rate by modification of embryo transfer technique: a randomized clinical trial. Fertil Steril 2010; 94:2424-6. [PMID: 20451185 DOI: 10.1016/j.fertnstert.2010.03.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
Abstract
In this randomized trial study, two groups of infertile women (n=55) aged≤40 years underwent in vitro fertilization or intracytoplasmic sperm injection treatment cycles with or without 0.2 mL of air pushed into the catheter after embryo transfer. The implantation and clinical pregnancy rates were statistically significantly higher in the study group than in the controls. This improvement on standard ET technique may advance clinical pregnancy rates.
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Affiliation(s)
- Tahereh Madani
- Endocrinology and Female Infertility Department, Reproductive Medicine Research Center, Royan Institute, ACECR, Tehran, Iran.
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17
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Sroga JM, Montville CP, Aubuchon M, Williams DB, Thomas MA. Effect of delayed versus immediate embryo transfer catheter removal on pregnancy outcomes during fresh cycles. Fertil Steril 2010; 93:2088-90. [DOI: 10.1016/j.fertnstert.2009.07.1664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 07/06/2009] [Accepted: 07/27/2009] [Indexed: 10/19/2022]
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Brown J, Buckingham K, Abou-Setta AM, Buckett W. Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women. Cochrane Database Syst Rev 2010:CD006107. [PMID: 20091584 DOI: 10.1002/14651858.cd006107.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Julie Brown
- Obstetrics and Gynaecology, University of Auckland, FMHS, Auckland, New Zealand
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Sifer C, Cédrin-Durnerin I, Hugues JN, Poncelet C. [Views of each member of an Assisted Reproductive Technologies centre on the embryo transfer procedure]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2009; 37:645-652. [PMID: 19589713 DOI: 10.1016/j.gyobfe.2009.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 04/27/2009] [Indexed: 05/28/2023]
Abstract
The embryo transfer (ET) is probably the key step of Assisted Reproductive Technologies (ART), end point of the collaboration of a multidisciplinary clinical team and an infertile couple. Thus, a perfect knowledge of available data regarding ET is required to optimize the results of ART. Indeed, numerous published studies demonstrate the impact of defined parameters onto the effectiveness of ET procedure. The aim of this study is to provide views of physicians dealing with ART, i.e. endocrinologist, ultrasound scan specialist, surgeon and biologist to put in perspective questions and answers about ET.
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Affiliation(s)
- C Sifer
- Service d'histologie-embryologie-cytogénétique, CHU Jean-Verdier, AP-HP, avenue du 14-Juillet, 93143 Bondy, France.
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Kosmas IP, Janssens R, De Munck L, Al Turki H, Van der Elst J, Tournaye H, Devroey P. Ultrasound-guided embryo transfer does not offer any benefit in clinical outcome: a randomized controlled trial. Hum Reprod 2007; 22:1327-34. [PMID: 17289683 DOI: 10.1093/humrep/dem001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ultrasound-guided embryo transfer (ET) is widely suggested as a standard clinical practice that improves overall embryo implantation and pregnancy rates. Various studies of this issue suffer from methodological pitfalls, so that a randomized controlled trial, which overcomes these problems, might be valuable. METHODS Three hundred women aged <40, who underwent fresh ET, were included in this randomized, double-blind controlled trial. The K-J-SPPE echo tip soft catheter was used for the ultrasound-guided ET and the traditional K-Soft catheter for ETs not using ultrasound. One experienced operator performed all ETs. The primary study outcome was overall pregnancy rate (defined as the number of positive hCG results per transfer). RESULTS No significant differences between groups were found regarding baseline patient and embryological characteristics, except for male factor and unexplained infertility (higher in the blind and ultrasound-guided ET group, respectively, P < 0.05). Overall pregnancy rates were 53.3 and 51.3% in the ultrasound-guided and blind ET group, respectively. Two ectopic pregnancies were reported in each group. Difficulty in cervical negotiation did not differ between the two groups. CONCLUSIONS In patients undergoing ET by an experienced operator, ultrasound guidance did not provide any benefit in terms of overall clinical pregnancy and embryo implantation rates.
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Affiliation(s)
- I P Kosmas
- Centre for Reproductive Medicine, Dutch-Speaking Brussels Free University, Brussels, Belgium.
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Brown JA, Buckingham K, Abou-Setta A, Buckett W. Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women. Cochrane Database Syst Rev 2007:CD006107. [PMID: 17253582 DOI: 10.1002/14651858.cd006107.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- J A Brown
- University of Auckland, Obstetrics and Gynaecology, FMHS, Auckland, New Zealand.
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Abstract
PURPOSE OF REVIEW Embryo transfer is arguably the most critical step in assisted reproduction. The purpose of this article is to review the different aspects of the procedure in the light of recent evidence. RECENT FINDINGS Randomized trials have shown that significantly higher pregnancy rates are obtained when embryo transfer is performed under ultrasound guidance, the embryos are deposited in the middle part of the uterine cavity, an atraumatic technique is used and when low-dose aspirin is routinely administered following the procedure. Blood in the catheter and leaving the embryos inside it for more than 120 s diminish the pregnancy rate significantly. Air in the catheter, immediate removal of the catheter, performing two transfers in the same cycle, prolonged bed rest, sexual intercourse after embryo transfer or the use of sildenafil do not affect the results. Based on currently available evidence, Cochrane reviews have concluded that the live birth rate is not increased by delaying embryo transfer from day two to three or to the blastocyst stage, and that single embryo transfer leads to lower live birth rates than the transfer of two embryos. The value of a mock transfer a few days before the actual procedure has been challenged as the position of the uterus may change. The effect of holding the cervix with a volsellum, routinely administering antibiotics and the superiority of one catheter over the others is still to be determined. SUMMARY Recent studies confirm the importance of the various aspects of embryo transfer. More randomized studies are needed to further evaluate them.
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Affiliation(s)
- Hassan N Sallam
- Department of Obstetrics and Gynaecology, University of Alexandria and Alexandria Fertility Center, Alexandria, Egypt.
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Embryo transfer—a critique of the factors involved in optimizing pregnancy success. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.ics.2004.01.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Levi Setti PE, Albani E, Cavagna M, Bulletti C, Colombo GV, Negri L. The Impact of Embryo Transfer on Implantation—A Review. Placenta 2003; 24 Suppl B:S20-6. [PMID: 14559026 DOI: 10.1016/s0143-4004(03)00187-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Embryo transfer has received little clinical attention and has been, until recently, the most inefficient step in in-vitro fertilization (IVF). In this article, the authors review the literature and their personal experience regarding the process of intrauterine transfer of embryos, which remains the object of much discussion. Factors which appear to influence implantation rates are: contamination of the catheter tip with cervical bacteria, stimulation of uterine contractions during the procedure, the type of catheter, ultrasound guidance during the transfer, and the position of the embryos in the uterine cavity. Easy and atraumatic transfer is essential for successful implantation and the embryos need to be placed in the middle of the cavity, away from the fundus. Knowing, beforehand, the position and length of the uterus can provide better results and may reduce the rate of ectopic pregnancies. Evidence from randomized studies has supported this claim. Despite the number of available studies controlling certain variables, most authors, even using the same catheter, ultrasound guidance and/or a trial transfer use different protocols or similar instruments in different ways. Standardization of the transcervical intrauterine transfer of embryos in a large randomized study is needed before definitive conclusions can be drawn. The goal of improved implantation and pregnancy rates deserve these efforts.
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Affiliation(s)
- P E Levi Setti
- Operative Unit of Reproductive Medicine, Humanitas Clinical Institute, Via Manzoni 56, I-20156 Rozzano, Italy [corrected].
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Karande V, Hazlett D, Vietzke M, Gleicher N. A prospective randomized comparison of the Wallace catheter and the Cook Echo-Tip catheter for ultrasound-guided embryo transfer. Fertil Steril 2002; 77:826-30. [PMID: 11937141 DOI: 10.1016/s0015-0282(01)03247-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To compare the performance of a new coaxial catheter system with an echo-dense tip (Cook Echo-Tip catheter) with a Wallace catheter during ultrasound-guided ET. DESIGN Prospective, randomized study. SETTING Private academically affiliated infertility center. PATIENT(S) Two hundred fifty-one patients undergoing IVF-ET. INTERVENTION(S) The patients underwent ultrasound-guided ET by a single physician with a standardized technique alternately using one of the two catheters. MAIN OUTCOME MEASURE(S) Implantation rates, pregnancy rates, ease of transfer, visualization, and status of catheter tip. RESULT(S) The echo-dense tip of the Cook Echo-Tip catheter was consistently seen with ultrasound guidance, minimizing the need for catheter movement to identify the tip. Implantation rate (30% vs. 35%), clinical pregnancy rate (57% vs. 55%), and ongoing pregnancy rate (49% vs. 47%) were similar in both groups. CONCLUSION(S) The Cook Echo-Tip catheter with its echogenic tip simplifies ultrasound-guided ET, but pregnancy success rates are similar to those obtained when a Wallace catheter is used.
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Affiliation(s)
- Vishvanath Karande
- Center for Human Reproduction and the Foundation for Reproductive Medicine, Chicago, Illinois, USA.
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