1
|
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.
Collapse
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.
| |
Collapse
|
2
|
D’Angelo A, Panayotidis C, Alteri A, Mcheik S, Veleva Z. Evidence and consensus on technical aspects of embryo transfer. Hum Reprod Open 2022; 2022:hoac038. [PMID: 36196080 PMCID: PMC9522404 DOI: 10.1093/hropen/hoac038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Ultrasound-guided embryo transfer (US-GET) is a widely performed procedure, but standards for the best practice are not available.
OBJECTIVE AND RATIONALE
This document aims to provide an overview of technical aspects of US-GET after considering the published data and including the preparation for the embryo transfer (ET) procedure, the actual procedure, the post-procedure care, associated pathologies, complications and risks, quality assurance and practitioners’ performance.
SEARCH METHODS
A literature search for evidence on key aspects of the ET procedure was carried out from database inception to November 2021. Selected papers (n = 359) relevant to the topic were analysed by the authors. The following key points were considered in the papers: whether ultrasound (US) practice standards were explained, to what extent the ET technique was described and whether complications or incidents and how to prevent such events were reported. In the end, 89 papers could be used to support the recommendations in this document, which focused on transabdominal US-GET.
OUTCOMES
The relevant papers found in the literature search were included in the current document and described according to the topic in three main sections: requirements and preparations prior to ET, the ET procedure, and training and competence for ET. Recommendations are provided on preparations prior to ET, equipment and materials, ET technique, possible risks and complications, training and competence. Specific aspects of the laboratory procedures are covered, in particular the different loading techniques and their potential impact on the final outcomes. Potential future developments and research priorities regarding the ET technique are also outlined.
LIMITATIONS, REASONS FOR CAUTION
Many topics were not covered in the literature review and some recommendations were based on expert opinions and are not necessarily evidence based.
WIDER IMPLICATIONS
ET is the last procedural step in an ART treatment and is a crucial step toward achieving a pregnancy and live birth. The current paper set out to bring together the recent developments considering all aspects of ET, especially emphasizing US quality imaging. There are still many questions needing answers, and these can be subject of future research.
STUDY FUNDING/COMPETING INTEREST(S)
No funding. ADA has received royalties from CRC Press and personal honorarium from Cook, Ferring and Cooper Surgical. The other co-authors have no conflicts of interest to declare that are relevant to the content of this article.
Collapse
Affiliation(s)
- Arianna D’Angelo
- Wales Fertility Institute, Swansea Bay Health Board, University Hospital of Wales, Cardiff University , Cardiff, UK
| | - Costas Panayotidis
- Attiki Iatriki advanced gynaecological ultrasound and hysteroscopic centre private practice , Pallini, Athens, Greece
| | | | - Saria Mcheik
- European society of human reproduction and embryology (ESHRE) Central Office , Strombeek-Bever, Belgium
| | - Zdravka Veleva
- Helsinki University Central Hospital , Helsinki, Finland
| |
Collapse
|
3
|
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.
Collapse
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:
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
Affiliation(s)
| | - Tin-Chiu Li
- Assisted Reproductive Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| |
Collapse
|
7
|
Yayla Abide C, Ozkaya E, Sanverdi I, Bostancı Ergen E, Kurek Eken M, Devranoglu B, Bilgiç BE, Kilicci C, Kayatas Eser S. Prospective Randomized Trial Comparing Embryo Transfers of Cases with and without Catheter Rotation during Its Withdrawal. Gynecol Obstet Invest 2018; 83:397-403. [PMID: 29758560 DOI: 10.1159/000489493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/21/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare embryo transfer (ET) technique based on catheter rotation during its withdrawal in cases with unexplained infertility in a prospective, randomized trial (NCT03097042). METHODS Two hundred intracytoplasmic sperm injection (ICSI) patients undergoing ET with cleaving or blastocyst-stage fresh embryos were randomized into 2 groups: cases with (n = 100), and without (n = 100) catheter rotation during its withdrawal. Groups were matched for age and some clinical parameters. A soft catheter was used to transfer a single embryo with catheter rotation during its withdrawal in the study group and without rotation in the control. The use of a stiff catheter or tenaculum was not needed in any case. Groups were compared in terms of cycle characteristics and clinical pregnancy rates. RESULTS Pregnancy rate was significantly higher in the study group (41 vs. 26%, p = 0.04). Clinical pregnancy rate was also significantly higher in the study group (39 vs. 25%, OR 1.9 [1.1-3.5], p = 0.05). On the other hand, the ongoing pregnancy rate was similar between the 2 groups (33 vs. 23%, p = 0.2). CONCLUSION Catheter rotation during its withdrawal may be associated with increased pregnancy and clinical pregnancy rates; however, the difference in ongoing pregnancy rates did not reach statistical significance.
Collapse
|
8
|
Maher MA, Sayyed TM, Elkhouly N. Cervical mucus removal prior to intrauterine insemination: a randomized trial. BJOG 2017; 125:841-847. [PMID: 29078018 DOI: 10.1111/1471-0528.15003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To detect if removing the cervical mucus before performing intrauterine insemination (IUI) could improve pregnancy outcomes in patients with unexplained infertility. DESIGN Prospective randomized study. SETTING An Egyptian University Hospital. POPULATION Seven hundred and fourteen couples with unexplained infertility who underwent intrauterine insemination (IUI) with or without cervical mucus removal. METHODS Using computer-generated numbers, patients were randomly allocated to cervical-mucus-removal (removed from both internal and external os) or non-mucus-removal groups. Only participants were blinded as to group assignment. MAIN OUTCOME MEASURES The clinical pregnancy rate. RESULTS Of 714 IUI patients between November 2014 and March 2017, 361 were in the mucus removal group, and 353 in the non-mucus-removal group. Difficult catheterization was encountered in 17 cases out of 666 (2.6%) 12 in the cervical-mucus-removal group and five in the non-mucus-removal group). A total of 666 IUI cycles were completed while 48 were either cancelled or lost in their follow-up. The clinical pregnancy rate was significantly higher in the mucus-removal group [31.0% (n = 112)] than in the non-mucus-removal group [21.8% (n = 77); P = 0.005]. Ovarian hyperstimulation developed in 33 (4.6%) cases: 18 cervical mucus-removal and 15 non-mucus-removal. All except one were mild and managed with outpatient care. CONCLUSIONS Cervical mucus removal before IUI could improve pregnancy outcomes in women with unexplained infertility. TWEETABLE ABSTRACT Cervical mucus removal before IUI can improve pregnancy outcomes.
Collapse
Affiliation(s)
- M A Maher
- Obstetrics and Gynaecology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt.,Al-Hayat National Hospital, Khamis-Mushait, Saudi Arabia
| | - T M Sayyed
- Obstetrics and Gynaecology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - N Elkhouly
- Obstetrics and Gynaecology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| |
Collapse
|
9
|
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]
|
10
|
Craciunas L, Tsampras N, Fitzgerald C. Cervical mucus removal before embryo transfer in women undergoing in vitro fertilization/intracytoplasmic sperm injection: a systematic review and meta-analysis of randomized controlled trials. Fertil Steril 2014; 101:1302-7. [DOI: 10.1016/j.fertnstert.2014.01.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/08/2014] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
|