Copper levels in cervical mucus of copper intrauterine device users versus non-users

We found higher copper levels in the cervical mucus of Cu‐IUD users compared with non‐users.

Microenvironment of the Lower Reproductive Tract: Focus on the Cervical Mucus Plug

The female lower reproductive tract microbiota is a complex ecosystem comprising various microorganisms that play a pivotal role in maintaining women's reproductive well-being. During pregnancy, the vaginal microbiota undergoes dynamic changes that are important for a successful gestation. This review summarizes the implications of the cervical mucus plug microenvironment and its profound impact on reproductive health. Further, the symbiotic relationship between the vaginal microbiome and the cervical mucus plug is highlighted, with a special emphasis on how this natural barrier serves as a guardian against ascending infections. Understanding this complex host-microbes interplay could pave the way for innovative approaches to improve women's reproductive health and fertility.

Tissue expression analysis of cervical mucus proteome

Cervical mucus is a viscous fluid functioning as a cervix plug. Products of the endometrial and cervical glands can be detected in the cervical mucus. Cervical mucus is further enriched with transudate originating from the fallopian tubes and proteins originating from the ovaries, peritoneum and distant tissues. With increasing levels of ovarian estrogens, the properties of cervical mucus for possible collection and processing change appropriately. For these reasons, we chose a group of 10 patients treated in the center of assisted reproduction by controlled ovarian stimulation for in vitro fertilization. This study focuses on the proteomic characterization of cervical mucus and localizes the possible sources of the identified proteins. The most abundant proteins were extracellular proteins, mainly mucins; however, most of the identified proteins, present usually in lower quantities, were of intracellular origin. The tissue analysis revealed that proteins from female reproductive organs are also expressed in other tissues in addition to female reproductive organs, but also proteins specific to the testis, liver, placenta, retina, and cerebellum. This study confirms the suitability and high potential of cervical mucus as a source of proteomic bio-markers not only for the dia-gnosis of the female reproductive tract.

A Comparison of App-Defined Fertile Days from Two Fertility Tracking Apps using Identical Cycle Data

OBJECTIVE

The Natural Cycles app employs daily basal body temperature to define the fertile window via a proprietary algorithm and is clinically established effective in preventing pregnancy. We sought to i) compare the app-defined fertile window of Natural Cycles to that of CycleProGo™, an app that uses BBT and cervical mucus to define the fertile window and ii) compare the app-defined fertile windows to the estimated physiologic fertile window.

STUDY DESIGN

Daily BBT were entered into Natural Cycles from 20 randomly selected regularly cycling women with at least 12 complete cycles from the CycleProGo database. The proportion of cycles with equivalent (+/-1 cycle day) fertile-window starts and fertile-window ends was determined. The app -defined fertile windows were then compared to the estimated physiologic fertile window using Peak mucus to estimate ovulation.

RESULTS

Fifty seven percent of cycles (136/238) had equivalent fertile-window starts and 36% (72/181) had equivalent fertile-window end days. The mean overall fertile-window length from Natural Cycles was 12.8 days compared to 15.1 days for CycleProGo (p<0.001). The Natural Cycles algorithm declared 12%-30% of cycles with a fertile-window start and 13%-38% of cycles with a fertile-window end within the estimated physiologic fertile window. The CycleProGo algorithm declared 4%-14% of cycles with a fertile-window start and no cycles with a fertile-window end within the estimated physiologic fertile window.

CONCLUSIONS

Natural Cycles designated a higher proportion of cycles days as infertile within the estimated physiologic fertile window than CycleProGo.

IMPLICATIONS

Use of cervical mucus in addition to BBT may improve the accuracy of identifying the fertile window. Additional studies with other markers of ovulation and the fertile window would give additional insight into the clinical implications of app-defined fertile window differences.

The barrier functions of crude cervical mucus plugs against HIV-1 infection in the context of cell-free and cell-to-cell transmission

OBJECTIVE

The cervical mucus plugs are enriched with proteins of known immunological functions. We aimed to characterize the anti-HIV-1 activity of the cervical mucus plugs against a panel of different HIV-1 strains in the contexts of cell-free and cell-associated virus.

DESIGN

A cohort of consenting HIV-1-negative and HIV-1-positive pregnant women in labour was recruited from Mthatha General Hospital in the Eastern Cape province of South Africa, from whom the cervical mucus plugs were collected in 6 M guanidinium chloride with protease inhibitors and transported to our laboratories at -80 °C.

METHODS

Samples were centrifuged to remove insoluble material and dialysed before freeze--drying and subjecting them to the cell viability assays. The antiviral activities of the samples were studied using luminometric reporter assays and flow cytometry. Time-of-addition and BlaM-Vpr virus-cell fusion assays were used to pin-point the antiviral mechanisms of the cervical mucus plugs, before proteomic profiling using liquid chromatography-tandem mass spectrometry.

RESULTS

The proteinaceous fraction of the cervical mucus plugs exhibited anti-HIV-1 activity with inter-individual variations and some degree of specificity among different HIV-1 strains. Cell-associated HIV-1 was less susceptible to inhibition by the potent samples whenever compared with the cell-free HIV-1. The samples with high antiviral potency exhibited a distinct proteomic profile when compared with the less potent samples.

CONCLUSION

The crude cervical mucus plugs exhibit anti-HIV-1 activity, which is defined by a specific proteomic profile.

Vaginal cytology and cervical mucus as tools to predict ovulation time in small ruminants

The possibility of using cervical mucus and vaginal cytology as tools to predict ovulation time was assessed in 11 ewes and 11 does raised under tropical conditions. Every 12 h from progesterone removal to ovulation, estrus behavior, cervical mucus, vaginal cytology, and ovarian ultrasound exams were performed. In goats, vaginal cytology had 88% of accuracy on detecting the ovulation time. However, in sheep, there was no cell pattern in the vaginal cytology and cervical mucus varied at ovulation. In conclusion, both vaginal cytology and mucus evaluation may be useful tools to determine the ovulation time in goats; however, both strategies are less accurate in sheep.

Correlation between cervical carcinogenesis and tobacco use by sexual partners

PURPOSE

Investigating the effects of active smoking, passive smoking and semen of tobacco smoking sexual partners on the carcinogenesis of uterine cervix.

INTRODUCTION

It is now well-established that persistence of Human Papillomavirus (HPV) infection is the strongest epidemiologic factor associated with intraepithelial neoplasia and cancer of cervix, as well as in other related locations such as in the vagina, vulva, anus, oral cavity, etc. A 1999 study indicates that the worldwide HPV prevalence in cervical carcinomas is 99,7 per cent. Multiple factors seem to intervene on cervical carcinogenesis, many of them related to tobacco, especially by direct local carcinogenic effect and local immunosuppression. Many studies have also shown that active or passive smoking in women (family-work environment, meeting places, etc.) greatly affects the occurrence, progression and degree of malignancy of carcinogenesis. Furthermore, particularly increased levels of nicotine and cotinine in the cervical mucus as well as prostate sperm fluids and urinary cotinine:creatinine ratios in smokers and passive smokers indicate that tobacco constituents do indeed reach the uterine cervix and lead to increased modification of DNA in cervical epithelium, suggesting biochemical evidence consistent with smoking as a cause of cervical cancer. The research presented today, though it took place over 30 decades ago (1975-1986 at the University Gynecological and Obstetric Clinic of Homburg ad Saar), we hope will serve as a reminder and contributing factor for further examination of the increased risk of cervical cancer in non-smoking women living with smoking partners.

STUDY

The study analyzed a total of one thousand five-hundred and forty (1,540) medical history sheets (krankenblätter) of women aged from eighteen to seventy-four (18-74) years old that were admitted, treated, examined (PAP TEST) or referred for further tests by their family physicians to the Homburg ad Saar Clinic between 1975-1986. The study evaluated the general medical history of the 1,540 women with a special focus on gynecological and obstetric related data and gathered additional information from patients through written questionnaires completed via phone, mail or personal interviews. Among a range of factors and data studied during the research, our current presentation and discussion will focus on the development of cervical neoplasms in women, examining results from three different study groups: smokers, passive-smokers and women with smoking sexual partners.

RESULTS

Five hundred and forty-four cases (544) out of the overall study sample of one thousand five-hundred and forty (1,540) women, were identified as cases with pathological cell abnormalities (35.32%). Following diagnosis and treatment of transient lesions due to various inflammations (vaginitis, cervicitis etc.) one hundred and twelve (112) cases (20.59%) showed varying degrees of mild/reversible up to CIN 1-3 intraepithelial lesions. From the above sample of one hundred and twelve 112 cases, nineteen cases (19) were smoke free women who never smoked themselves, were not exposed to passive smoking and had non-smoker partners (16.96%). Forty-four (44) cases (39.29%) were female smokers, twenty-two (22) cases (19.64%) were women exposed to regular passive smoking (family-work environment) with a smoke-free partner and twenty-seven (27) cases (24.11%) were women non-smokers with a smoker partner. From the above findings, intraepithelial lesions were found to be higher (and with a progressive malign ratio) on the study groups that were associated with tobacco use either active or passive and therefore, the synergistic harmful effect of smoking, progressively from passive smokers to active smokers, is clearly evident on the occurrence and progression of cervical malignancies. As already mentioned above, the presence of HPV has been widely proven to be almost exclusively the cause of different degrees of neoplasia in the cervix for more than 99.7% of cervical carcinogenesis. However, the harmful effects of a) active smoking, b) passive smoking and c) the exposure to tobacco constituents through an active smoker partner, in women, should be sought and possibly attributed to the catalytic reduction of cervical self-defense and overall cervical immunity disruption which results to the exposure of cervix to elevated levels of nicotine-cotinine and cancer-causing chemicals related to smoking, may work together with certain types of HPV limiting the natural ability of the cervix to defend against carcinogenesis and therefore increase the likelihood of developing cancer.

CONCLUSION

Since the almost exclusively cause of cervical neoplasms is due to the presence and carcinogenic activity of HPV, the harmful/synergistic effect of smoking, passive smoking and partner smoking cannot be attributed to the direct carcinogenic effect of nicotine but to the overall damage of the immune system as we as the reduction of cervical self-defense making it more vulnerable to the carcinogenic nature of HPV, in particular the increased pathogenic types 16 and 18. Lastly, another potential correlation that could be further examined is the potential effects of tobacco constituents in cervical fluids on the self-defense system of the male reproductive system.

Resolving speculations of methodological inadequacies in the standardized protocol for characterizing women's fertility: Comment on Lobmaier and Bachofner (2018)

Lobmaier and Bachofner (2018) suggest a series of methodological practices to increase the accuracy and reliability of determining a woman's fertile window, claiming the standardized protocol for characterizing women's fertility by Blake et al. (2016) is inadequate. These practices include observing participants for purportedly fertile sessions a considerable time before the LH surge, and using salivary ferning and cervical mucus evaluation as real-time measures of current fertility. Here I explain that Lobmaier and Bachofner's (2018) recommendations decrease rather than increase the likelihood of observing women during peak fertility. I also summarize the pertinent literature on salivary ferning and cervical mucus evaluations, showing that neither method has sufficient sensitivity and specificity to characterize peak fertility. Using meta-analytic data of 10K menstrual cycles, I then show that the protocol provided by Blake et al. (2016) recruits women when conception probability is at its peak and is statistically higher than the window recommended by Lobmaier and Bachofner (2018).

Intrauterine insemination versus intracervical insemination in donor sperm treatment

BACKGROUND

The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI).

OBJECTIVES

To compare the effectiveness and safety of intrauterine insemination (IUI) and intracervical insemination (ICI) in women who start donor sperm treatment.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL in October 2016, checked references of relevant studies, and contacted study authors and experts in the field to identify additional studies. We searched PubMed, Google Scholar, the Grey literature, and five trials registers on 15 December 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) reporting on IUI versus ICI in natural cycles or with ovarian stimulation, and RCTs comparing different cointerventions in IUI and ICI. We included cross-over studies if pre-cross-over data were available.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We collected data on primary outcomes of live birth and multiple pregnancy rates, and on secondary outcomes of clinical pregnancy, miscarriage, and cancellation rates.

MAIN RESULTS

We included six RCTs (708 women analysed) on ICI and IUI in donor sperm treatment. Two studies compared IUI and ICI in natural cycles, two studies compared IUI and ICI in gonadotrophin-stimulated cycles, and two studies compared timing of IUI and ICI. There was very low-quality evidence; the main limitations were risk of bias due to poor reporting of study methods, and serious imprecision.IUI versus ICI in natural cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in natural cycles (odds ratio (OR) 3.24, 95% confidence interval (CI) 0.12 to 87.13; 1 RCT, 26 women; very low-quality evidence). There was only one live birth in this study (in the IUI group). IUI resulted in higher clinical pregnancy rates (OR 6.18, 95% CI 1.91 to 20.03; 2 RCTs, 76 women; I² = 48%; very low-quality evidence).No multiple pregnancies or miscarriages occurred in this study.IUI versus ICI in gonadotrophin-stimulated cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in gonadotrophin-stimulated cycles (OR 2.55, 95% CI 0.72 to 8.96; 1 RCT, 43 women; very low-quality evidence). This suggested that if the chance of a live birth following ICI in gonadotrophin-stimulated cycles was assumed to be 30%, the chance following IUI in gonadotrophin-stimulated cycles would be between 24% and 80%. IUI may result in higher clinical pregnancy rates than ICI (OR 2.83, 95% CI 1.38 to 5.78; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). IUI may be associated with higher multiple pregnancy rates than ICI (OR 2.77, 95% CI 1.00 to 7.69; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). This suggested that if the risk of multiple pregnancy following ICI in gonadotrophin-stimulated cycles was assumed to be 10%, the risk following IUI would be between 10% and 46%.We found insufficient evidence to determine whether there was any clear difference between the groups in miscarriage rates in gonadotrophin-stimulated cycles (OR 1.97, 95% CI 0.43 to 9.04; 2 RCTs, overall 67 pregnancies; I² = 50%; very low-quality evidence).Timing of IUI and ICIWe found no studies that reported on live birth rates.We found a higher clinical pregnancy rate when IUI was timed one day after a rise in blood levels of luteinising hormone (LH) compared to IUI two days after a rise in blood levels of LH (OR 2.00, 95% CI 1.14 to 3.53; 1 RCT, 351 women; low-quality evidence). We found insufficient evidence to determine whether there was any clear difference in clinical pregnancy rates between ICI timed after a rise in urinary levels of LH versus a rise in basal temperature plus cervical mucus scores (OR 1.31, 95% CI 0.42 to 4.11; 1 RCT, 56 women; very low-quality evidence).Neither of these studies reported multiple pregnancy or miscarriage rates as outcomes.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine whether there was a clear difference in live birth rates between IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment. There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates. Very low-quality data suggested that in gonadotrophin-stimulated cycles, ICI may be associated with a higher clinical pregnancy rate than IUI, but also with a higher risk of multiple pregnancy rate. We concluded that the current evidence was too limited to choose between IUI or ICI, in natural cycles or with ovarian stimulation, in donor sperm treatment.

A Feasibility Study of Women's Confidence and Comfort in Use of a Kit to Monitor Ovulation

INTRODUCTION

The focus of this study was to examine whether low-income adult women will use ovulation test strips, a menstrual calendar chart, thermometer, temperature graph, and cervical mucus assessment to monitor their ovulation time and other menstrual changes. Women's confidence in their ability to detect ovulation time and understand the menstrual cycle changes were also examined.

METHODS

This is a descriptive study. Twenty-two low-income women aged 18 to 39 years living in medically underserved neighborhoods participated in this study. The women were introduced to and taught how to use a knowing your body (KB) kit, which consisted of ovulation test strips, monthly calendars for menstrual logs, digital thermometer for basal body temperature, and graphs to chart temperature. The women were interviewed 6 to 8 weeks later to confirm their experiences with the use of the KB kit.

RESULTS

Ninety-one percent of the women used the ovulation test strips (mean, 3.8 strips); 77.3% were very to extremely confident that they could properly use the ovulation strip, 54.6% knew when they ovulated, and 31.8% could use the thermometer to confirm when they were ovulating. Seventy-three percent of the women were very to extremely comfortable using the ovulation test strips, 81.8% using the thermometer, 45.5% using the temperature graph, and 31.8% using the TwoDay Method (cervical mucus observation).

DISCUSSION

The use of the ovulation test strip and other content of the KB kit provides a new opportunity for low-income women to learn about their bodies by monitoring their ovulation time and other menstrual changes as a pregnancy planning and early pregnancy recognition tool.

ASSISTING WOMEN TO CONCEIVE: A CLINICAL UPDATE ON FERTILITY-AWARENESS

This update on fertility-awareness has two principle aims. First, to highlight the gaps in women's understanding of when in the menstrual cycle it is possible to conceive and second, to outline the accurate use of fertility-awareness methods to ensure correctly timed intercourse for a pregnancy. Nurses and midwives who provide sexual and reproductive healthcare services will find this clinical practice update particularly helpful.

The effect of clomiphene citrate vs. letrozole on post-coital tests

PURPOSE

To determine if letrozole is less likely to create a hostile cervical mucus than clomiphene citrate.

MATERIALS AND METHODS

Post-coital testing compared at time of peak follicular maturation in women attaining mature follicles in first or second cycle of these two drugs. The study was randomized. Intercourse occurred at least 8-16 hours before.

RESULTS

Poor post-coital tests were found in twice the frequency in letrozole cycles than clomiphene citrate cycles.

CONCLUSIONS

Despite its shorter half-life, letrozole seems to be as least as likely, if not more, to adversely affect cervical mucus.

Comparison of Abstinence and Coital Frequency Between 2 Natural Methods of Family Planning

INTRODUCTION

The length of periodic abstinence, due to overestimation of the fertile phase of the menstrual cycle, is often a cause for dissatisfaction, discontinuation, and user error with natural family planning (NFP) methods. The objective of this research was to compare the length of required abstinence (ie, estimated fertility) and coital frequency between 2 NFP methods.

METHODS

This was an analysis of data from a 12-month prospective comparison study in which participants were randomized into either an electronic hormonal fertility monitor (EHFM) group or a cervical mucus monitoring (CMM) group-both of which included a fertility algorithm as a double check for the beginning and end of the estimated fertile window. The number of days of estimated fertility and coitus was extracted from each menstrual cycle of data, and t tests were used to compare the means of these 2 variables between the 2 NFP methods.

RESULTS

The study involved 197 women (mean [SD] age 29.7 [5.4]) who used the EHFM to estimate the fertile window and 160 women (mean [SD] age 30.4 [5.3]) who used CMM to estimate the fertile window. They produced 1,669 menstrual cycles of data. After 12 months of use, the EHFM group had statistically fewer days of estimated fertility than the CMM group (mean [SD] days, 13.25 [2.79] vs 13.68 [2.99], respectively; t = 2.07; P = .039) and significantly more coitus (mean [SD] coital acts, 4.22 [3.16] vs 4.05 [2.88], respectively; t = 1.17; P = .026).

DISCUSSION

The use of the EHFM seems to provide more objectivity and confidence in self-estimating the fertile window and using nonfertile days for intercourse when avoiding pregnancy.

Successful sex pre-selection using natural family planning

The objective of the study was to test the hypothesis that gender can be preselected by timing coitus in relation to ovulation, the marker of ovulation being the Peak symptom according to the Billings Method. A blind prospective study of 99 couples wishing to preselect the sex of their child was conducted in Nigeria, using the Post-Peak approach of Billings Method for males and Pre-Peak for females. Research co-ordinators examined the 'post-conception' form within four months of conception. This form recorded the timing of coitus prior to conception, and from this, the sex of child was predicted. 94 of the couples had a child of pre-selected sex showing a method success of 94.9%. 78 of 81 predicting a male were successful (96.3%) and 16 of the 18 predicting a female (88.9%). There was one user-failure, a couple who wanted a girl, timed coitus as for a boy, which they had. The study indicates that where comprehensive instruction is provided, the sex of a child can be preselected with a high degree of confidence by timing coitus, using the Post-Peak approach of Billings Method for males and Pre-Peak for females.

Frozen-thawed rhesus sperm retain normal morphology and highly progressive motility but exhibit sharply reduced efficiency in penetrating cervical mucus and hyaluronic acid gel

The preservation of the genetic diversity of captive populations of rhesus monkeys is critical to the future of biomedical research. Cryopreservation of rhesus macaque sperm is relatively simple to perform, yields high post-thaw motility, and theoretically, provides via artificial insemination (AI) a way to easily transfer genetics among colonies of animals. In the interest of optimizing semen cryopreservation methods for use with vaginal AI, we evaluated the ability of frozen-thawed rhesus sperm to penetrate periovulatory cervical mucus (CM). Motile sperm concentration of pre-freeze ("fresh") and post-thawed ("thawed") samples from five different males were normalized for both computer assisted sperm motion analysis and CM penetration experiments. Sperm samples were deposited into slide chambers containing CM or gel composed of hyaluronic acid (HA) as a surrogate for CM and numbers of sperm were recorded as they entered a video field a preset distance from the sperm suspension-CM (or HA) interface. Fresh and thawed sperm were dried on glass slides, "Pap"-stained, and assessed for changes in head dimensions and head and flagellar shape. While retaining better than 80% of fresh sperm progressive motility, thawed sperm from the same ejaculate retained on average only 18.6% of the CM penetration ability. Experiments using HA gel yielded similar results only with reduced experimental error and thus improved detection of treatment differences. Neither the percentage of abnormal forms nor head dimensions differed between fresh and thawed sperm. While findings suggests that sperm-CM interaction is a prominent factor in previous failures of vaginal AI with cryopreserved macaque sperm, neither sperm motility nor morphology appears to account for changes in the ability of cryopreserved sperm to penetrate CM. Our data points to a previously unidentified manifestation of cryodamage which may have implications for assessment of sperm function beyond the cervix and across mammalian species.

The multiple uses of ethinyl estradiol for treating infertility

PURPOSE

To demonstrate the usefulness of ethinyl estradiol, a drug no longer commercially produced in most countries, in treating various fertility related issues.

METHODS

Twenty to 40 micrograms of ethinyl estradiol can be started on day 2 or 3 of the cycle and combined with exogenous gonadotropin can be useful in improving hostile cervical mucus or inducing ovulation in women with hypergonadotropic amenorrhea. It can be used from the day after stopping clomiphene citrate to help negate the adverse effect of this drug on cervical mucus.

RESULTS

Successful pregnancies have been achieved saving the couple the expense of intrauterine insemination (IUI) or using donor oocytes.

CONCLUSIONS

This drug can be very helpful for those physicians who treat each infertile woman on an individual basis and carefully ascertain the couple's input as to their preferences rather than a "herd" type of medicine.

Tissue-based classification of HPV infections of the uterine cervix and vagina (mucosal HPV infections)

Terminology of HPV infections of the uterine cervix and vagina is somewhat confusing, with various terms having different meanings to different authors. This prompted us to revise the current terminology and propose a "tissue-based" classification of HPV infections of the cervix and vagina (mucosal HPV infections), which is based on histological appearance of the lesions and should be clear-cut in everyday practice of managing these patients. We hope the proposed nomenclature may overcome some of the confusion and controversy that exist in the current terminologies describing these lesions.

Techniques for preparation prior to embryo transfer

BACKGROUND

Embryo transfer (ET) is the final and most vulnerable step in in vitro fertilisation (IVF) treatment. Pregnancy rates after ET may be influenced by several factors including cervical preparation, the performance of a dummy or mock transfer, the choice of catheter, the use of ultrasound guidance, removing the mucus or blood on the catheter, and straightening of the utero-cervical angle. Recent research has focused on improving the embryo transfer technique in the hope of increasing the success rates of IVF. This review focused on preparation techniques as it is unclear whether these simple interventions will make ET an easier procedure with higher success rates and lower complication rates.

OBJECTIVES

To determine whether different preparation techniques prior to ET result in improved IVF outcomes.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO were searched (November 2008). The citation lists of relevant publications, reviews, and included studies were handsearched. Experts in the field were contacted to identify any unpublished trials.

SELECTION CRITERIA

Only truly randomised controlled trials of the interventions straightening the utero-cervical angle, dummy transfer prior to ET, cervical and endometrial preparation, and embryo afterloading were included. The primary outcomes were live birth rate and pregnancy rate per woman randomised. Participants were women with any type of subfertility undergoing IVF treatment and reaching the ET stage.

DATA COLLECTION AND ANALYSIS

Two review authors critically appraised potentially eligible studies. Ten studies were included in this review and data were independently extracted by two review authors. Disagreements were resolved by discussion and involvement of a third author. Risk of bias was also independently assessed by two authors. Dichotomous outcome data were expressed as Peto odds ratios. Subgroup analysis and the investigation of heterogeneity were planned.

MAIN RESULTS

At the time of ET, there was no evidence of benefit with the following interventions: full bladder, removal of cervical mucus, flushing the endocervical canal or the endometrial cavity. We did not identify any eligible studies for dummy transfer, changing patient position, the use of a tenaculum, or embryo afterloading.

AUTHORS' CONCLUSIONS

On the basis of the evidence in this review, no specific implications for practice are made. It is recommended, in general, that more, larger studies are done on ET preparation techniques. The studies need to be of a higher quality with better explained methods, more specified inclusion and exclusion criteria, and more participants.

Effect of oviductal proteins on structural and functional characteristics of cryopreserved sperm in Murrah buffaloes

The present study was undertaken to elucidate the effect of non-luteal oviductal proteins on sperm characteristics in Murrah buffaloes. Oviducts from healthy buffaloes were collected immediately after slaughter and the oestrous cycle phase was determined as either luteal or non-luteal based on ovarian morphology. Non-luteal oviducts (n = 80) were flushed from the isthmic end of the oviduct with PBS, fluid was centrifuged at 10,000 g at 4 degrees C for 20 min and then dialysed and clarified. The supernatant obtained was lyophilized to concentrate the protein and stored at -20 degrees C till use. Sixteen good quality ejaculates from four Murrah buffalo bulls were collected using an artificial vagina. After fresh semen analysis, each ejaculate was split into two parts and extended in Tris-citrate-egg yolk glycerol dilutor. Part I of the split ejaculate was treated with non-luteal oviductal proteins at the dose rate of 1 mg/ml of diluted semen, while part II remained as control. The extended semen was equilibrated for 4 h at 5 degrees C, filled in 0.5 ml French straws, exposed to LN(2) vapour, plunged into LN(2) and then stored at -196 degrees C. The equilibrated and frozen-thawed semen was evaluated for sperm motility, viability, acrosomal integrity, cervical mucus penetration test and hypo-osmotic sperm swelling test (HOST). In frozen-thawed semen, the percentage of sperm motility, viability and acrosomal integrity was significantly (p < 0.05) higher in the treatment group compared to the control group. The incorporation of non-luteal oviductal proteins in the extender increased the ability of sperm to penetrate cervical mucus both after equilibration and the freeze-thaw process. Similarly, the proportion of sperm with intact plasma membrane, as revealed by HOST values, was also significantly (p < 0.05) higher in the treatment group (32.6%) than the control group (27%) in frozen-thawed semen. It was inferred that incorporation of non-luteal whole oviductal fluid proteins improved the sperm quality in frozen-thawed semen in Murrah buffaloes.

Papanicolaou smears: to swab or not to swab

OBJECTIVE

To determine whether cleaning the cervix with a cotton swab affects the quality of the conventional Papanicolaou smear.

DESIGN

Prospective, single-blinded randomized case-control study.

SETTING

Two academic family medicine teaching units and 1 community family practice site.

PARTICIPANTS

Female patients, 18 to 65 years of age, who presented for a routine Pap smear in the family practice setting were randomized into the Swab Group (n = 300) or the No Swab Group (n = 316).

INTERVENTION

Before the Pap smear, the cervix of patients in the Swab Group was wiped with a cotton swab until visibly free of mucus. In the No Swab Group, the cervix was not cleaned with a cotton swab before the Pap smear.

MAIN OUTCOME MEASURES

The quality of the conventional Pap smear was determined by the presence or absence of endocervical cells noted on the pathology report.

RESULTS

There was no major difference in the quality of the Pap smear in terms of the adequacy of endocervical cells between the Swab and No Swab Group.

CONCLUSION

Cleaning the cervix with a cotton swab does not appear to affect the quality of the conventional Pap smear in terms of adequacy of endocervical cells. This implies that the practice of wiping or not wiping the mucus from the cervix before taking the Pap smear can be employed at the discretion of the clinician.

Comparison of fern and evaporation tests for detection of ruptured fetal membranes

Timely diagnosis of ruptured fetal membranes during the pregnancy is important. This study in the Islamic Republic of Iran compared the sensitivity and specificity of the evaporation test that requires no special equipment with the standard fern test requiring a microscope. Two groups of 50 pregnant women were studied: 1 with artificially ruptured membranes (gold standard) and 1 with intact membranes. The positive and negative predictive values of the fern test were 92% and 96% and for the evaporation test were 89% and 98%. The evaporation test is a simple, easy and non-expensive diagnostic test for ruptured membranes.

Fertility awareness-based methods for contraception: systematic review of randomized controlled trials

CONTEXT

Fertility awareness-based (FAB) methods of family planning estimate the fertile days of the menstrual cycle whether by observing fertility signs such as cervical secretions and basal body temperature or by monitoring cycle days. The efficacy and acceptability of these methods are unclear.

METHODS

We retrieved and analyzed all randomized controlled trials that examined any FAB method used for contraception.

RESULTS

Because of poor methods and reporting, pregnancy rates could not be determined. A trial in Colombia found similar numbers of pregnancies among women randomized to the ovulation and symptothermal methods, but a trial in Los Angeles observed more pregnancies in the group assigned to the ovulation method. In the two American trials, recruitment of participants was unexpectedly difficult. Continuation rates were poor.

CONCLUSION

Despite intensive training and ongoing support, most participants in these trials discontinued prematurely. The comparative efficacy of these methods remains unknown. However, with the ovulation and symptothermal methods, pregnancies appear to be common; method continuation rates are low.

Effect of oviductal proteins on sperm functions and lipid peroxidation levels during cryopreservation in buffaloes

A study was undertaken to find out the effect of addition of oviductal proteins on sperm functions and lipid peroxidation (LPO) levels in buffaloes. Oviductal flushings were collected from apparently healthy buffalo genital tracts (nonluteal and luteal stage of estrous cycle), centrifuged (3000 rpm; 30 min), filtered (0.2 microm) and frozen at -20 degrees C. The proteins in pooled nonluteal and luteal oviductal fluid were precipitated overnight using ammonium sulphate, centrifuged (10,000 rpm; 30 min) and dialyzed (>10 kDa). After protein estimation, aliquots of samples containing 10 mg proteins were lyophilized in cryovials and stored frozen at -20 degrees C. Six pooled good quality ejaculates collected by artificial vagina method from two Murrah buffalo bulls were utilized for the study. After fresh semen analysis, each pooled ejaculate was split into three parts and extended in Tris-Egg yolk-Citrate extender (20% egg yolk: 7% glycerol), so that final dilution yielded approximately 60 million sperm cells/ml and cryopreserved in 0.5 ml French straws (30 million sperm cells per straw) in LN2 (-196 degrees C). Before freezing, the nonluteal and luteal oviductal proteins (NLOP &LOP) were incorporated at the concentration of 1mg/ml of extended semen. The equilibrated and frozen thawed (37 degrees C for 30s) semen was evaluated for motility, viability and acrosomal integrity, bovine cervical mucus penetration test and hypo-osmotic sperm swelling test. Besides these tests, LPO level was assessed in sperm and seminal plasma in equilibrated and frozen thawed semen. Results revealed that addition of oviductal proteins to semen before freezing convey beneficial effect in terms of spermatozoan motility, viability and acrosomal integrity. Nonluteal oviductal proteins favored significantly (P < 0.05) higher sperm penetration distance in cervical mucus (23.00+/-1.15 mm) than the control group (15.00+/-3.46 mm) in frozen thawed semen. Similarly, swollen sperm percentage was also significantly (P < 0.05) higher in NLOP treated group than the LOP included and control groups. In frozen thawed spermatozoa, the LPO level was significantly (P < 0.05) lower in NLOP added group than the LOP added and control group. It was inferred that incorporation of oviductal proteins in extender before freezing reduced the lipid peroxidation levels in buffalo spermatozoa during cryopreservation and thereby improved the post-thaw semen quality.

Isolation and characterization of heparin and gelatin binding buffalo seminal plasma proteins and their effect on cauda epididymal spermatozoa

Seventy semen ejaculates were obtained from 14 Murrah buffalo bulls and were subjected to plasma separation immediately after collection by centrifugation at 2000 rpm for 20 min and stored in liquid nitrogen until analysis. In the seminal plasma the total protein concentration were estimated and the heparin and gelatin binding (HB and GB) proteins were isolated using heparin and gelatin affinity column chromatography. The molecular weight of individual isolated HB and GB protein was determined by SDS-PAGE analysis. Buffalo bull spermatozoa was collected from cauda epididymis under aseptic conditions and was used for the in vitro fertility tests (i.e. bovine cervical mucus penetration test (BCMPT) and hypo-osmotic swelling test (HOST)). The heparin and gelatin binding buffalo seminal plasma proteins were used in six concentrations i.e. 10, 20, 30, 40, 50 and 60 microg/ml to test their effect on in vitro fertility assessment of cauda epididymal spermatozoa. The overall mean values of total protein, HB and GB proteins were recorded as 29+/-2.7, 2.61 and 0.2mg/ml, respectively. Eighteen total protein bands were observed in the range of 12-127 kDa. Eight major HB proteins were isolated in the range of 13-71 kDa. Seven major GB proteins were isolated in the range of 13-61 kDa in the buffalo seminal plasma. The mean penetration distance (mm) travelled by the buffalo cauda spermatozoa was maximum in HB proteins (26.9+/-0.6) followed by GB proteins (25.4+/-0.6) and control (21.2+/-1.4). The difference in BCMPT values between protein treated and control group was significant (P<0.05). Almost similar trend in the effect of protein on values of HOST percentage in both HB and GB proteins treated semen samples were recorded (66.4+/-0.65 and 66.1+/-0.6, respectively). The difference in HOST values between proteins treated and control group (50.4+/-2.0) was significant (P<0.05). The present results indicate that among the isolated proteins, 4 proteins were commonly seen in both the heparin and gelatin-sepharose affinity column chromatography, and the addition of buffalo seminal plasma proteins improved the in vitro sperm functions (40 microg/ml gave best results) of buffalo cauda spermatozoa.

Modulation of post-thaw sperm functions with oviductal proteins in buffaloes

A study was undertaken to determine the effects of oviductal proteins obtained from various stages of the estrous cycle on spermatozoa characteristics in buffaloes. Oviducts were collected from apparently healthy buffalo genital tracts (nonluteal and luteal stage of estrous cycle) and separated into isthmus and ampulla. Each segment of oviduct (nonluteal and luteal) was flushed with PBS (pH 7.4). The flushing obtained was centrifuged (3000 rpm; 30 min), filtered (0.2 microm) and frozen at -20 degrees C. The proteins in pooled nonluteal isthmic and ampullary and luteal isthmic and ampullary fluids were precipitated overnight using ammonium sulphate, centrifuged (10000 rpm; 30 min) and dialyzed (>10 kDa). After protein estimation, aliquots of samples containing 10 mg proteins were lyophilized in cryovials and stored in frozen form at -20 degrees C. Six pooled good-quality ejaculates collected by artificial vagina method from two Murrah buffalo bulls were utilized for the study. After fresh semen analysis, each pooled ejaculate was splited into five parts and extended in Tris-egg yolk-citrate extender (20% egg yolk; 7% glycerol), so that final dilution yielded approximately 60 million sperm cells per ml, and cryopreserved in 0.5 ml French straws (30 million sperm cells/straw) in LN(2) (-196 degrees C). Before freezing, nonluteal isthmic and ampullary and luteal isthmic and ampullary proteins were incorporated at the rate of 1mg/ml of extended semen. The equilibrated and frozen-thawed (37 degrees C for 30 s) semen was evaluated for motility, live %, acrosomal integrity percentage, bovine cervical mucus penetration test and hypo-osmotic sperm swelling test. Besides this, spermatozoa from treatment and control groups were incubated at 37 degrees C for 6 h in sperm TALP. Among the nonluteal and luteal oviductal proteins, the former maintained higher (P < 0.05) post-thaw sperm motility, live %, and acrosomal integrity than the control group. Between the isthmic and ampullary proteins, the isthmic proteins incorporated group maintained higher (P < 0.05) post-thaw sperm motility, live %, and acrosomal integrity. Similarly, higher sperm penetration distance in cervical mucus was recorded in nonluteal isthmic proteins incorporated group. But, irrespective of the stage of an estrous cycle, isthmic proteins included group maintains higher sperm membrane integrity as revealed by higher (P < 0.05) swollen sperm percentage in response to hypo-osmotic solution than the ampullary proteins included and control groups. Similarly, at any time during incubation the sperm motility and viability was higher (P < 0.05) in isthmic proteins treated group than the ampullary and control group. But, the same trend was not observed in terms of acrosomal integrity percentages. It is inferred that inclusion of oviductal proteins in the extender prior to freezing improved post-thaw semen quality. Oviductal proteins differentially affected sperm function depending upon the region of oviduct and the stage of estrous cycle at which the proteins were obtained.

Assessment of in vitro sperm characteristics after flow cytometric sorting of frozen-thawed bull spermatozoa

The effect of processing prior to sex-sorting, re-freezing and thawing of frozen-thawed bull spermatozoa on in vitro sperm characteristics was investigated. Frozen-thawed bull spermatozoa (three bulls; three ejaculates per bull) were prepared for sorting by washing (FT-WASH) or gradient centrifugation (FT-GRADIENT) and evaluated for motility and forward progressive motility (FPM) after processing, staining, sorting and incubation (3 h; 37 degrees C). After frozen-thawed samples were processed and analyzed using a high-speed cell sorter, aliquots were removed and re-frozen and thawed (FTF-WASH; FTF-GRADIENT). Non-sorted frozen-thawed spermatozoa (FT-CONTROL) were also re-frozen and thawed (FTF-CONTROL). Spermatozoa from all treatments were assessed for penetration of an artificial cervical mucus at 0 h after sorting or thawing, and for motility, FPM and acrosomal status after 3-h incubation (37 degrees C). Frozen-thawed spermatozoa prepared by gradient centrifugation before sorting were sorted more efficiently than washed samples (P < 0.05). However, after sorting (FT) or thawing (FTF) and incubation, the percentage of motile spermatozoa and FPM rating was lower for GRADIENT than WASH (21.5 +/- 3.39%; 1.4 +/- 0.16 FPM versus 48.6 +/- 4.02%, 2.6 +/- 0.16 FPM; P < 0.01). Frozen-thawed sorted spermatozoa (FT) penetrated in greater numbers (151.0 +/- 19.50 spermatozoa) and distance (56.3 +/- 5.11 mm) in the artificial cervical mucus and had a higher proportion of motile spermatozoa (65.5 +/- 2.77%) and FPM rating (2.8 +/- 0.12) after incubation than spermatozoa that had been re-frozen and thawed after sorting (FTF: 14.0 +/- 3.67 spermatozoa, 21.6 +/- 3.05 mm, 12.2 +/- 1.31% and 1.2 +/- 0.10 FPM, respectively; P < 0.001). Regardless of processing prior to sorting, frozen-thawed sorted and non-sorted spermatozoa migrated similar distances in the artificial cervical mucus (FT-WASH: 60.0 +/- 1.2 mm; FT-GRADIENT: 57.2 +/- 0.76 mm; FT-CONTROL: 51.7 +/- 0.69 mm). The results of this preliminary study suggested that frozen-thawed bull spermatozoa can be efficiently sorted into high purity X- and Y-chromosome enriched samples with retained functional capacity.

Natural family planning revisited

The article focuses on the role of natural family planning NFP as a component of reproductive health. It distinguishes NFP from the concept of fertility awareness method. Furthermore, the effectiveness of NFP as determined by previous studies is presented and the advantages and disadvantages of NFP are highlighted. Additionally, factors that influence the use of NFP methods are examined. Finally, delivery strategies and options for mainstreaming NFP into reproductive health services are identified and discussed.

Impact des techniques de transfert sur l’implantation

Embryo transfer is an important step in the success of IVF treatment. All efforts should be made to avoid difficult embryo transfers provoking bleeding or uterine contractions. Evaluation before IVF treatment, including a trial transfer and a uterine ultrasonography, should allow one to evaluate the transfer step, anticipate problems, and thus improve treatment. An hysteroscopy can be useful for uterine cavity exploration. It is also important to remove cervical mucus before introduce the transfer catheter. It is essential to deposit embryos as gently as possible during IVF, avoiding manoeuvres that might trigger uterine contractions which could adversely affect the results of this treatment. Soft catheters perform better, and ultrasound-guidance facilitates embryo transfer. Progesterone administration starting on the day of oocyte retrieval induces a decrease in uterine contraction frequency on the day of ET (embryo transfer). Both Wallace and CDD catheters perform similarly. Trial catheterization on the day of ET could prevent most of the unanticipated procedural difficulties during the transfer.

Vulvar mucus observations and the probability of pregnancy

OBJECTIVE

To assess the day-specific and cycle-specific probabilities of conception leading to clinical pregnancy, in relation to the timing of intercourse and vulvar mucus observations.

METHODS

This was a retrospective cohort study of women beginning use of the Creighton Model Fertility Care System in Missouri, Nebraska, Kansas, and California. Data were abstracted from Creighton Model Fertility Care System records, including women's daily standardized vulvar observations of cervical mucus discharge, days of intercourse, and clinically evident pregnancy (conception). Established statistical models were used to estimate day-specific probabilities of conception.

RESULTS

Data were analyzed from 1681 cycles with 81 conceptions from 309 normally fertile couples (initially seeking to avoid pregnancy) and from 373 cycles with 30 conceptions from 117 subfertile couples (who were initially trying to achieve pregnancy). The highest probability of pregnancy occurred on the peak day of vulvar mucus observation (.38 for normally fertile couples and.14 for subfertile couples). The probability of pregnancy was greater than.05 for normally fertile couples from 3 days before to 2 days after the peak, and for subfertile couples from 1 day before to 1 day after the peak. The cycle-specific probability of conception correlated with the quality of mucus discharge in normally fertile couples but not in subfertile couples.

CONCLUSION

Standardized vulvar observations of vaginal mucus discharge identify the days with the greatest likelihood of conception from intercourse in normal fertility and subfertility and provide an indicator of the overall potential for conception in a given menstrual cycle in normal fertility.

Intravaginal progesterone insert to synchronize return to estrus of previously inseminated dairy cows

An intravaginal progesterone insert (CIDR insert; 1.38 g of progesterone) was evaluated for synchronization of returns to estrus (SR), conception rate (CR), and pregnancy rate (PR) in dairy cows previously artificially inseminated (AI). Healthy, nonpregnant, lactating Holstein cows, > or = 40 and < or = 150 d postpartum at eight commercial farms were used. Cows detected in estrus and receiving AI 2, 3, or 4 d after one injection of PGF2alpha (25 mg) were assigned as either controls (n = 945), or to receive a CIDR insert (n = 948) for 7 d (14 to 21 +/- 1 d after AI). Cows were observed for returns to estrus from 18 to 26 +/- 1 d after initial AI (resynchrony period) and were reinseminated if in estrus. Vaginal mucus on CIDR inserts (97.3% retention) at removal was scored: 1 = no mucus; 2 = clear; 3 = cloudy; 4 = yellow; and 5 = red or brown. Percentage of cows in estrus (SR) during the 3 d after CIDR insert removal was contrasted to the highest 3-d cumulative percentage in estrus for controls. Cows conceiving to initial AI were omitted in calculations of SR, CR, and PR during resynchrony. Mucous scores of 3 or 4 (mild irritation) were observed in 65% of cows and a score of 5 (more severe irritation) was observed in 2%; otherwise, health was unaffected. The PR to initial AI was lower for cows subsequently receiving CIDR inserts than for controls (32.7 vs. 36.7%). The CIDR insert increased SR (34.1 vs. 19.3% in 3 d) and overall estrus detection (43% in 4 d vs. 36% in 9 d) compared with controls. For the 9-d resynchrony period, CR and PR for CIDR-treated (26.7, 12.2%) and control (30.9, 11.1%) cows did not differ significantly. The CIDR inserts improved synchrony of returns to estrus, slightly reduced PR to initial AI, but did not affect CR or PR to AI during the resynchrony period.

Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects

There are many potential mechanisms of action for the intrauterine device (IUD), which vary by type of IUD (inert, copper, or hormonal). This paper reviews the evidence for each potential mechanism of action. On the basis of available data for fertilization rates and clinical pregnancy rates, the relative contribution of mechanisms acting before or after fertilization were quantitatively estimated. These estimates indicate that, although prefertilization effects are more prominent for the copper IUD, both prefertilization and postfertilization mechanisms of action contribute significantly to the effectiveness of all types of intrauterine devices.

Production of cervical mucus in ewes treated with exogenous progestagen and oestrogen

The production of cervical mucus was measured at intervals of 6 hr about the onset of oestrus in ewes treated with exogenous progestagen administered by the intramuscular or intravaginal route. There was a quadratic pattern of production with peak values early in the oestrous period. Although there were no differences between groups in the total amount of mucus produced, levels recorded in untreated ewes were lower in the pre-oestrous period. Within the intravaginal progestagen group, those ewes which exhibited oestrus within 42 hr of sponge withdrawal produced greater quantities of cervical mucus than did animals which came into heat after this time. This relationship was not evident within the intramuscular progesterone group. It was concluded that the variable cervical mucus response observed after the cessation of treatment may contribute to the lowered fertility commonly observed following the synchronization of oestrus. The cervical mucus response to injected steroids was recorded in spayed ewes. This was a specific linear response to exogenous oestrogen. Progesterone priming resulted in higher levels of cervical secretions from 24 to 42 hr after the administration of oestradiol benzoate (ODB). Intravenous administration of ODB caused an earlier but short-lived response.

Differences in sperm migration through cervical mucus in vitro relates to sperm colonization of the oviduct and fertilizing ability in goats

Sperm migration in estrous cervical mucus can be used to measure the ability of spermatozoa to migrate through the genital tract. The relationship of this test with the sperm colonization of the isthmus, and its impact on fertility has not been evaluated in goats. Our objectives were to determine the differences among spermatozoa of different bucks in their ability to penetrate homologous cervical mucus in vitro and to determine the relationship between sperm displacement through cervical mucus and the ability of spermatozoa to colonize the oviduct and penetrate IVM oocytes, in vivo. Sperm migration in cervical mucus was assessed in flat capillary tubes with a phase contrast microscope. In the first experiment, fresh semen was used to establish differences between males in the ability of their spermatozoa to migrate in cervical mucus. In the second experiment, goats in estrus were inseminated with fresh spermatozoa from males with significant differences in mucus migration ability, and sperm numbers were evaluated at the UTJ. In the third experiment, the fertilization efficiency of IVM oocytes transferred to the oviduct of estrous females inseminated with semen from the same males as earlier, was used to assess the relationship between the mucus migration test and the in vivo fertilization performance of their spermatozoa. Spermatozoa from different males varies significantly in sperm migration efficiency in cervical mucus (15.5a +/- 1.2; 14.9a +/- 1.4; 17.5ab +/- 1.2; 17.0ab +/- 1.5; 19.7b +/- 1.2; 20.1b +/- 1.4 mm; media +/- S.E.M. for males A-F, respectively, P < 0.05). Spermatozoa from males with different mucus migration efficiency values produced different sperm populations at the oviduct reservoir of inseminated females (1,233 +/- 92.3 versus 28.8 +/- 17.0 spermatozoa of males with high and low relative migration efficiency, respectively, P < 0.02). Spermatozoa from males with different mucus migration efficiency values have different fertilization rates of IVM oocytes transferred to oviduct (47/96 (49.0%) versus 25/91 (27.5%) for males with high and low relative migration efficiency, respectively, P < 0.05). Cumulative results suggest that sperm migration in cervical mucus is related to the ability of spermatozoa to colonize the oviduct and to fertilize matured oocytes in vivo.

Optimizing the embryo transfer technique

The technique of embryo transfer is very crucial and great attention and time should be given to this step. In order to optimize the embryo transfer technique, several precautions should be taken. The first and most important is to avoid the initiation of uterine contractility. This can be achieved by the use of soft catheters, gentle manipulation and by avoiding touching the fundus. Secondly, proper evaluation of the uterine cavity and utero-cervical angulation is very important, and can be achieved by performing dummy embryo transfer and by ultrasound evaluation of the utero-cervical angulation and uterine cavity length. Another important step is the removal of cervical mucus so that it does not stick to the catheter and inadvertently remove the embryo during catheter withdrawal. Finally, one has to be absolutely sure that the embryo transfer catheter has passed the internal cervical os and that the embryos are delivered gently inside the uterine cavity.