Difficult ET Research Articles

Outcome of mock embryo transfer before the first IVF cycle: A randomized control trial.

Background There is a lack of agreement among fertility specialists with regard to the routine use of mock embryo transfer (MET) before each in vitro fertilization (IVF) treatment cycle. While MET may be beneficial with previous difficult embryo transfer cases, its routine use before first IVF cycle has not been evaluated.ObjectiveTo find out the effect of MET before the first IVF cycle on clinical pregnancy rate.Materials and Methods This is a single-centre randomized controlled trial with a balanced randomization (1:1), carried out between November 2015 and October 2017, with 200 subjects at Homerton university hospital, London, randomized into either MET or control. The primary outcome was clinical pregnancy rate (detection of heart activity on the ultrasound scan), the secondary outcome measures were live birth rate, miscarriage and multiple pregnancy rates, difficult ETs, rate of blood or mucus on the catheter tip.Results No significant differences were observed in the baseline or cycle characteristics between the two groups. The clinical pregnancy rate was similar between the MET and control groups based on both intension to treat and per protocol analyses (p = 0.98, p = 0.92, respectively). Additionally, no significant difference was seen in the live birth rate in both groups on intension to treat and per protocol analyses (p = 0.67, p = 0.47), respectively.ConclusionOur study concludes that MET prior to first IVF cycle may not improve the success rate in young women without risk factors for a difficult embryo transfer.

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

To establish the relationship between the degree of difficulty of ET and pregnancy rate (PR), with a view to proposing an algorithm for the objective assessment of ET. Retrospective, observational study. Invitro fertilization unit. Women undergoing assisted reproductive technology (ART) with ET after IVF/intracytoplasmic sperm injection, in whom fresh embryo transfer or frozen-thawed embryo transfer was performed. None. Clinical pregnancy rate (CPR). A total of 7,714 ETs were analyzed. The CPR was significantly higher in the cases of easy ET compared with difficult ET (38.2% vs. 27.1%). Each instrumentation needed to successfully deposit the embryos in the fundus involves a progressive reduction in the CPR: use of outer catheter sheath (odds ratio [OR] 0.89; 95% confidence interval [CI] 0.79-1.01), use of Wallace stylet (OR 0.71; 95% CI 0.62-0.81), use of tenaculum (OR 0.54; 95% CI 0.36-0.79). Poor ultrasound visualization significantly diminish the CPR. The CPR decreases progressively with the use of additional maneuvers during ET. An objective classification of the instrumentation applied during ET is proposed.

The MACOCHA score is feasible to predict intubation failure of nonanesthesiologist intensive care unit trainees

PurposeEndotracheal intubation (ET) in intensive care unit (ICU) patients is regarded as more challenging than elective intubations in the operating room. Despite challenging conditions in ICU, trainees are often the initial operators performing ET. Because nonanesthesiologist intensivists with limited experience in ET run most of the nonsurgical ICUs, it is of exceptional importance to identify patients with predictable difficult ET in advance to prepare for a difficult airway scenario and thus avoid severe complications. MethodsIn this prospective, observational, single-center study, we used a truncated MACOCHA score to evaluate intubation performance of nonanesthesiologist ICU trainees in an interdisciplinary medical ICU. ResultsWe show that (a) ET could be performed safely and without fatal complications in all cases; (b) the MACOCHA score is feasible on a nonanesthesiologist ICU; (c) a truncated MACOCHA score of at least 8 predicts failure of ICU trainees; and (d) availability of an ear, nose, and throat physician and an anesthesiologist is required to warrant successful management of difficult airways. ConclusionOur findings are a further step to implement the MACOCHA score into the standard admission procedure of an ICU to identify early those patients in whom additional support is needed in case of ET and to improve patient safety.

Echogenic Catheters and Embryo Transfer Standardization.

1.To describe the standardization process and protocols of the ET method at our center. 2.To compare the performance of non-echogenic catheters with echogenic catheters during ultrasound-guided ET. Retrospective analysis of 2630 ET performed at UNIFERTES during 1997-2014, to describe standardization process and to compare the percentage of difficult ET between echogenic and non-echogenic catheters. We tested 17 non-echogenic and three echogenic catheters. Many variables were associated with the ease of ET: informed patients, waiting time for the procedure, speculum use, clinical touch, uterine contractions, cervical mucus removal, presence of blood before or after the procedure, full bladder, ultrasound guidance, uterocervical angle, mock transfer, catheter type (soft or hard, echogenic or non-echogenic, with stylet or not), catheter loading technique, duration of embryo loading (time interval since the embryos were removed from the incubator for loading until the catheter is passed to the physician), transfer procedure (time interval from the catheter was handed to the physician until the embryos were discharged in the uterus), catheter tip placement, retained embryos, bed rest after ET, operator´s proficiency. The diversity of catheters used and the percentage of difficult transfers decrease as the use of echogenic catheters increases. This process is necessary to minimize variation, ensure high quality, safe and evidence-based practice, and improve outcomes. To standardize the ET method allowed a quicker and easier transfer. The use of echogenic catheters simplified ET procedures guided by abdominal ultrasound.

Successful pregnancy in vitrified/warmed blastocyst intrafallopian transfer

To analyze whether the use of blastocyst intrafallopian transfer is a feasible option in a case of repeated difficult ET. Case report. Public hospital. Forty-year old nulliparous patient. Transfer of two vitrified/warmed blastocysts into the right tube by means of laparoscopy. Successful ET, clinical pregnancy. Successful ET procedure resulting in positive ß-hCG and clinical pregnancy. In cases of repeated difficult ETs (regardless of whether the patient shows cervical adhesions or any type of genital malformations), blastocyst intrafallopian transfer can be a successful alternative approach.

Effect of hysteroscopy performed in the cycle preceding controlled ovarian hyperstimulation on the outcome of in vitro fertilization

Effect of hysteroscopy performed in the cycle preceding controlled ovarian hyperstimulation on the outcome of in vitro fertilization

Transcervical placement of a Malecot catheter after hysteroscopic evaluation provides for easier entry into the endometrial cavity for women with histories of difficult intrauterine inseminations and/or embryo transfers: a prospective case series

Objective: To evaluate a new technique designed to improve access to the endometrial cavity through tortuous and/or stenotic endocervical canals in women with histories of difficult IUIs, ETs, or endometrial biopsies. Design: Prospective case series. Setting: Tertiary care center. Patient(s): Women with histories of difficult intrauterine procedures because of tortuous and/or stenotic endocervical canals who continued to undergo treatment. Intervention(s): Hysteroscopic evaluation and/or correction of the endocervix, followed by transcervical placement of a Malecot catheter (CR Bard Inc., Covington, GA) for an average of 10 days. Main Outcome Measure(s): Improvement in the ease of access to the endometrial cavity during IUIs or ETs. Result(s): Thirty-two of 36 patients had significantly easier procedures after the placement and removal of a Malecot catheter. Conclusion(s): Hysteroscopic evaluation and placement of a Malecot catheter is a useful technique that allows easier entry through the cervical canal in patients in whom previous IUIs, ETs, and endometrial biopsies have been difficult. This procedure may lead to improved pregnancy rates, particularly with IVF-ET, as the ease of ET has been correlated with improved implantation rates.

How useful is cervical dilatation in patients with cervical stenosis who are participating in an in vitro fertilization-embryo transfer program? the bourn hall experience

Objective: To evaluate the place of cervical dilatation performed at the initial visit in an IVF-ET cycle in patients with known cervical stenosis. Design: Retrospective study. Setting: A tertiary care assisted conception unit. Patient(s): Fifty-seven patients who failed to conceive after a previous ET attempt and in whom the ET was classified as “difficult.” Intervention(s): Cervical dilatation under general anesthesia after pituitary suppression and before gonadotropin stimulation. Main Outcome Measure(s): Ease of the ET procedure and clinical pregnancy rate. Result(s): Eighteen (31.6%) of 57 women who failed to conceive after a previous attempt at IVF-ET achieved a clinical pregnancy after cervical dilatation. In 40 patients (70.2%), the subsequent ET was classified as “easy,” whereas in the other 17 (29.8%), it remained difficult. The pregnancy rate was significantly higher when the ET was easy than when it was difficult (40% versus 11.8%, P<.05). Conclusion(s): In patients with cervical stenosis and a previous difficult ET, cervical dilatation during the initial visit leads to an easier subsequent ET and improves the pregnancy rate.

In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix

Objective: To assess the impact of ET difficulty on IVF outcome and to optimize the ET procedure.Design: Retrospective analysis of IVF outcome by ET catheter type and ET difficulty. Prospective treatment and follow-up of patients with a history of extremely difficult cervical passage.Setting: Large university-based IVF program.Patient(s): All patients <40 years of age undergoing IVF-ET from September 1995 to May 1998.Intervention(s): Surgical correction of cervical stenosis.Main Outcome Measure(s): Pregnancy and embryo implantation rates.Result(s): Only 0.6% of ETs were “extremely difficult.” Pregnancy rates were not statistically significantly different among ETs graded easy, moderate, and difficult. In contrast, no pregnancies occurred in the rare “extremely difficult” ET group. Eight patients with a history of extremely difficult cervical passage underwent surgical correction of their cervical stenosis. Twelve postoperative IVF-ET in these women resulted in eight clinical pregnancies, six of which were multiple gestations. The embryo implantation rate of these cycles was 42.2%.Conclusion(s): Patients with a history of extremely difficult ET may benefit from hysteroscopic evaluation and possible modification of their cervical canal before a future IVF attempt.

Ectopic pregnancy after transmyometrial embryo transfer: case report

Objective: To report a case of ectopic pregnancy after transvaginal transmyometrial ET.Design: Case report.Setting: University-based IVF program.Patient(s): A woman with tubal subfertility and a history of difficult ETs.Intervention(s): Transvaginal transmyometrial ET performed to avoid a difficult transcervical ET.Main Outcome Measure(s): Expected improvement in the pregnancy rate in a selected group of patients.Result(s): Tubal pregnancy.Conclusion(s): Transmyometrial ET is an attractive alternative to difficult transcervical ET but is not free of complications.

Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis

Objective: To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. Design: Case reports describing two patients. Setting: Tertiary care, assisted reproduction practice. Patient(s): Two patients with cervical stenosis and a history of multiple failed cycles of IVF. Intervention(s): Laminaria tents were placed intracervically before ET. Main Outcome Measure(s): Presence of a gestational sac and fetal heartbeat on ultrasound. Result(s): Successful clinical pregnancies occurred in both patients after laminaria placement and ET. Conclusion(s): Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis.

Transmyometrial embryo transfer after difficult immediate mock transcervical transfer

To evaluate the place of ultrasound-directed transvaginal transmyometrial ET in a protocol using both the transcervical and transmyometrial routes in a step-wise fashion. A prospective descriptive clinical study. A university-based assisted conception unit. Thirteen patients who had difficult or impossible mock transcervical ET immediately before the real transfer. Ultrasound-directed transvaginal transmyometrial ET. Pregnancy and clinical pregnancy. Four patients became pregnant, including three with clinical pregnancies. In cases in which transcervical ET isd difficult or impossible, transvaginal transmyometrial ET is a viable option. The use of mock transcervical ET immediately before the real transfer would identify patients needing transmyometrial ET.