Easy Embryo Transfer Research Articles

P–359 Blastocyst quality, transfer difficulty and endometrial thickness affect clinical pregnancy after frozen embryo transfer (FET) of euploid blastocysts in the upper uterine cavity

Abstract Study question Which factors affect the clinical pregnancy rate (CPR) after single euploid frozen embryo transfers (FET), when the blastocyst is transferred in the upper uterine cavity area? Summary answer Blastocyst quality, embryo transfer difficulty and endometrial thickness affect the CPR in FET. What is known already There is a limited understanding of the factors affecting success rates after FET. The most important factors influencing implantation rates are patient characteristics, type of endometrial preparation, embryo quality and transfer difficulty. It has been shown that the position of the euploid blastocyst, measured as distance from the fundus (DFF) of the uterine cavity (mm), affects the implantation potential. Although the ideal location within the uterine cavity is still being debated in very heterogeneous patient populations, most studies have found that the highest pregnancy rates are obtained when the embryo is placed in the upper area of the uterine cavity. Study design, size, duration This single center retrospective cohort study included a total of 603 single euploid FET cycles, in the upper half of the uterine cavity, between January 2019 and November 2020 in ART Fertility Clinic Abu Dhabi, UAE. Participants/materials, setting, methods Trophectoderm biopsy samples were subjected to Next Generation Sequencing to screen the ploidy state. Vitrification and warming were performed using the Cryotop method (Kitazato, Biopharma). The full length of the uterine cavity and the longitudinal distance between the fundal endometrial surface and the air bubble after transfer were measured. Main results and the role of chance The patients were on average 33.9 (19–46) years old. The FET was performed in a natural cycle (NC) (n = 278) or hormone replacement therapy (HRT) (n = 325). Of the 603 transfers which had been performed in the upper half of the uterus, 412 (68.3%) resulted in a pregnancy and 311 (51.5%) in a clinical pregnancy. After bivariate analysis, the clinical pregnancy rate was significantly higher for high quality blastocysts (grade 1–2 versus 3–4) (p < 0.001), after easy embryo transfers (p = 0.001) and for higher endometrial thickness (p = 0.027). After performing a multivariate logistic regression analysis to consider the effect of all explanatory variables (age, Anti Müllerian hormone, body mass index, endometrial thickness, quality of the blastocyst, difficulty of the transfer [requirement of additional instrumentation], presence of mucus or blood on the transfer catheter, day 5 or day 6 biopsy, FET endometrial preparation), the clinical pregnancy was affected by the endometrial thickness: OR 1.20 [1.05–1.37], p = 0.007; transfer difficulty: OR 0.44 [0.25–0.79], p = 0.006; blastocyst quality 3: OR 0.38 [0.18–0.79], p = 0.01 and blastocyst quality 4: OR 0.15 [0.06–0.37], p < 0.0001. Age did not affect the clinical pregnancy after transferring a single euploid blastocyst: OR 1.03 [1.00–1.06], p = 0.052. Limitations, reasons for caution The limitation of this study was its retrospective nature and the small sample size. Other parameters may be important in live birth outcomes. Wider implications of the findings: Optimization of clinical pregnancy outcomes after FET depends on multiple factors. Even after transfer of euploid blastocysts in the upper uterine cavity, the endometrial thickness, transfer difficulty and blastocyst quality will still affect the clinical pregnancy outcomes. Trial registration number NA

Effect of embryo transfer difficulty on live birth rates studied in vitrified-warmed euploid blastocyst transfers.

The aim of this study was to investigate the relationship between the different manoeuvres employed or degrees of difficulty during embryo transfer and live birth rate (LBR) in frozen euploid (blastocyst) embryo transfer (FEET). A retrospective, observational study of women undergoing FEET was performed. If the catheter encountered any resistance in its passage through the cervix, a stepwise approach was used. Easy embryo transfer was defined as a direct embryo transfer or use of the outer sheath of the catheter. Difficult embryo transfer was defined as when the process required the use of a Wallace Malleable Stylet (Smiths Medical International Ltd., UK) without or with additional instrumentation such as a tenaculum or uterine sound. The analysis involved 370 FEET. LBR was significantly lower in difficult FEET procedures compared with easy ones (54.5% versus 40.5%, P = 0.026) but significance was lost after adjustment for confounders. Use of the outer sheath use did not affect LBR. Although LBR was significantly lower when the stylet, without or with a tenaculum, was required (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.34-0.93; P < 0.05), no statistically significant reduction was observed after adjustment for confounders (OR 0.81, 95% CI 0.45-1.47). No significant reduction in LBR was observed after adjustment for confounders between difficult and easy FEET, or when use of stylet without or with a tenaculum was required for embryo transfer. The lack of significance may be due to factors such as the sample size or the use of array comparative genomic hybridization analysis. Further studies are needed to confirm these results.

Pregnancy Outcome after Difficult Embryo Transfer in IVF-ET Cycles

Background: Embryo transfer (ET) is one of the most crucial steps in IVF/ICSI treatment. Although it, apparently, seems simple, it is an integral part of IVF/ICSI and can affect the outcome of the whole treatment cycle. The majority of couples (approximately 80%) who undergo IVF reach the ET stage, yet few pregnancies occur. The pregnancy rate after ET is dependent on multiple factors including embryo quality, endometrial receptivity, and the technique of the ET. Aim of the Work: The aim of the current study is to investigate the clinical and ongoing clinical pregnancy rates in women who experience difficult embryo transfer (ET) after IVF/ICSI cycle. Patients and Methods: This prospective cohort study was conducted at Dar Al-Teb Infertility and IVF Centerbetween January 2017 and January 2018. The study included 417 women planned to undergo ET. Results: The biochemical, clinical and ongoing clinical pregnancy rates were significantly lower in women who had difficult ET when compared to women who had easy ET [ORs 0.5, 95% CI (0.31 to 0.83); 0.48, 95% CI (0.29 to 0.79); 0.36, 95% CI (0.21 to 0.62); respectively]. Conclusion: Difficult ET is associated with significantly reduced biochemical, clinical and ongoing clinical pregnancy rates. Recommendations: ET should be smooth with easy passage of the transfer catheter. Since any uterine manipulation during ET adversely affects IVF results, therefore precaution should be taken to identify possibly difficult ET cases in advance.

Anatomical causes of difficult embryo transfer during in vitro fertilization

Identify, define and validate through statistical analysis the anatomical causes of difficult embryo transfers (ET). This observational study, carried out in 306IVF candidates, compared the frequency of anatomical anomalies of the uterus and cervix in women who underwent an easy ET with that in women who underwent a difficult ET. Anatomical anomalies were detected during an assessment of the cervix and uterus including transvaginal ultrasound, hysteroscopy and a mock transfer. Ease of ET was determined during the actual transfer procedure. An easy ET was achieved in 151patients, whereas difficulties occurred in 155patients, among whom 55patients underwent a "very difficult" ET. The most common anatomical characteristics associated with difficult ET were abnormal crypts in the cervical canal (86%) and tortuosity of the cervical canal (68%). Less frequent causes included: internal os contractions (28%) and pronounced anteversion of the uterus (26%). Very difficult ETs were associated with the presence of several causes. ET is the clinical step that has the most effect on IVF outcome. Difficult transfers are associated with a fall in pregnancy rates. The anatomical causes of difficult transfer identified in this study led to major changes in transfer procedure in our department and to the development of more adapted catheters.

Comparative Study Between Mock Embryo Transfer Prior To The Treatment Cycle and Real Embryo Transfer In In Vitro Fertilization

&lt;p&gt;&lt;strong&gt;Introduction&lt;/strong&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;A trial or mock embryo transfer (ET) may influence pregnancy rates and it performed prior to ET allows the clinician to assess the uterine cavity and the utero-cervical angle. The aim of this study is to compare the consistency of the type of ET in mock ET with real ET.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Material &amp;amp; Methods&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;A retrospective comparative analysis of patients who underwent in vitro fertilization or ICSI cycle from January 2014 to December 2014 in Halim Fertility Center was done. The type of transfer was divided into two groups: ‘easy’ or ‘difficult’. An easy ET was defined as a transfer that occurred without the use of manipulation or other instrumentation and difficult ET was considered when additional instrumentation was required.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;From the study, 103 patients who underwent Mock-ET, we found 58 patients (56.3%) with easy ET and 45 patients (43.7%) with difficult ET, which with hard catheter ET in 17 patients (16.5%), with osfander assistance in 20 patients (19.4%) and with stylet in 8 patients (7,8%). 58 patients with Easy Mock ET group were entirely easy real ET (100%) and 45 patients with difficult Mock ET group also entirely were difficult real ET (100%). The Statistical analysis shows no significant difference between the mock ET and real ET groups (p&amp;gt;0,05). In easy real ET, clinical pregnancy rates were 32.8% and in difficult real ET, clinical pregnancy rates were 26.7% with no significant difference between the groups (p&amp;gt;0,05).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Mock ET prior to the treatment cycle is consistent with real ET.&lt;/p&gt;

Office Hysteroscopy in Difficult Embryo Transfer; Case Report of Three Cases

Objectives: To facilitate embryo transfer technique in cases with previous failed or difficult transfer using office hysteroscopy. Study Design: Case report of 3 cases of previous difficult embryo transfer (ET). Methods: Hysteroscopic assisted insertion of cervical stent at the end of withdrawal bleeding in the stimulation cycle. This stent was used as a track for embryo transfer catheter. Results: One case cancelled before (embryo transfer) ET and the other 2 cases didn’t get pregnant in spite of easy embryo transfer. Conclusion: This hysteroscopic assisted ET technique may facilitate ET technique in cases with difficult embryo transfer due to deformed cervix.

Difficult embryo transfer (ET) components and cycle outcome. Which is more harmful?

Abstract Objective: To compare the impact of individual elements of difficult embryo transfer (D-ET): cervical traction (Cx-Tr), blood on outer sheath (Bl-OS), blood on transfer catheter (Bl-TC) and sounding (Snd) individually and in combination on clinical pregnancy rate (CPR) and implantation rates (IR) of ICSI cycles. Methods: A retrospective cohort study included 744 ICSI cycles. Easy embryo transfer (E-ET) was diagnosed if no resistance on passing the preloaded TC and the sheath through the cervix. Difficult transfer was defined if Cx-Tr and/or Snd was needed, and Bl-OS or Bl-TC was present. Cycle outcome was compared for E-ET and D-ET as a whole and individually with subgroups using Odds Ratio and 95% CI. Results: CPR for E-ET (45.6%) and D-ET (39.8%) is not statistically significantly different. Comparing E-ET with Cx-Tr, Bl-OS or Bl-TC, Snd showed significantly lower CPR with Bl-TC and Snd subgroups only. Although IR showed no significant difference between E-ET and over all components of D-ET it tended to be lower for Bl-TC and Snd subgroups. Conclusion: Cx-Tr and/or Bl-OS do not compromise CPR or IR. Only when Bl-TC and/or Snd the uterus at the time of ET is the CPR significantly undermined and IR tends to be impaired.

Methods employed to overcome difficult embryo transfer during assisted reproduction treatment.

Multiple steps, at both scientific and clinical level, are involved in assisted reproduction technology (ART). Optimization of each of these steps contributes to maximize the success of ART. Embryo transfer is one of the vital steps in ART. An easy embryo transfer increases the success of ART. Adequate training is required to undertake embryo transfer, but anatomical difficulties in completing this procedure alter the success of treatment. Difficult embryo transfer is challenging for clinicians but has an overwhelming negative impact on patients. Difficult embryo transfer may cause cervical or endometrial trauma with uterine contractions which can lead to unsuccessful implantation and poor outcome after ART. Literature review of published material looking at all interventions that were employed to overcome difficult embryo transfers during ART. We identified 5 methods (17 studies) were employed to overcome difficult embryo transfer which are: Hysteroscopic methods in 4 studies (2 case reports, 2 case series). Malecot catheters after hysteroscopic evaluation were used in 2 studies (1 case report, 1 case series). Dilators including hygroscopic dilators were used in 2 studies (1 case report, 1 case series) and mechanical dilators were used in 3 studies (2 case series, 1 RCT-patients 367). Intrafollopian transfer was reported in 1 case report. Transmyometrial embryo transfers were reported in 5 studies (2 case reports, 2 case series, 1 RCT). There were only two randomized controlled studies (RCTs) identified in the review. All other were either case series or case reports. We found that there was no uniform classification or grading of difficulty of embryo transfer in the literature. A grading system has been suggested in this review. We recommend that there should be a consensus guideline formulated for interventions to overcome difficult embryo transfer. A large multicenter randomized controlled study is required to compare different methods for women with difficult embryo transfer.

Appropriate timing of uterine cavity length measurement positively affects assisted reproduction cycle outcome

An appropriate and easy embryo transfer has a direct impact on pregnancy rates. Proper evaluation of the uterocervical axis and uterine depth are necessary for suitable embryo transfer. The aim of this study was to assess the appropriate time for cervical axis evaluation and uterine measurement. A total of 124 patients undergoing IVF treatment were included in the study. They were divided equally into two groups. In group I (62 women), uterine cavity depth was measured and the uterocervical axis was determined on day 2 or 3 of the menstrual cycle, and in group II (62 women) at the time of oocyte retrieval. There was a statistically significant difference in clinical pregnancy rates between the two groups (P = 0.006). Thirty-four women became pregnant in group I (64.2%) versus 19 women in group II (35.8%). In conclusion, uterine cavity measurement is necessary for suitable embryo transfer. It seems that the time of measurement significantly affects clinical pregnancy rate in IVF cycles. The best time for uterine measurement is on day 2 or 3 of menstruation.

Ultrasound Guidance Is Not Necessary During Easy Embryo Transfers

To determine whether the use of ultrasound (US) to guide embryo transfer (ET) in a population previously defined as likely to have easy transfer would change the implantation and pregnancy rates in an ICSI program. A total of 100 patients identified as likely to have easy transfer after mock transfer were divided into two groups: Group I, US-guided ET (N = 50) and Group II, ET without the aid of US (N = 50). Implantation and pregnancy rates were similar (p = 0.51, p = 0.29) for Group I (19.6%, 42%) and Group II (16.3%, 30%), as also was the abortion rate (p = 0.55) (Group I: 1/21; Group II: 2/15). As long as previous mock transfers are routinely performed during a cycle preceding assisted reproduction and the clinician considers transfer to be easy, ultrasound does not benefit the process of embryo transfer.

Cervical dilatation with hygroscopic rods prior to ovarian stimulation facilitates embryo transfer.

Embryo transfer is a critical factor affecting the success of IVF-the ease of embryo transfer has a direct impact on the success rate. The aim of this study was to assess the value of cervical dilatation with hygroscopic cervical rods (Dilapan-S) in patients with difficult embryo transfer. Fifty-four patients undergoing IVF treatment, who either failed to conceive after previous difficult embryo transfer or were noted to have difficult mock embryo transfer were retrospectively included in the study. In this way the patients acted as control for themselves. The Dilapan-S rods were placed intracervically and left for 4 h prior to starting gonadotrophin stimulation as an outpatient procedure. Of the 54 patients who originally had difficult embryo transfer, 43 patients (79.5%) had subsequent easy embryo transfer. Thirty patients managed to conceive, giving a clinical pregnancy rate of 55%. Cervical dilatation using hygroscopic dilators facilitates difficult embryo transfer and helps to improve the pregnancy rate.

The use of hygroscopic cervical rods (Dilapan-S TM) in patients with cervical stenosis undergoing in vitro fertilization

Objective: To assess the value of cervical dilatation with hygroscopic cervical rods (Dilapan-S TM) in patients with cervical stenosis prior to starting gonadotrophin stimulation.Design: retrospective study.Materials/Methods: 54 patients undergoing embryo transfer after IVF or IVF/ICSI treatment that either failed to conceive after previous difficult embryo transfer, or were noted to have cervical stenosis at the time of the mock embryo transfer, were included in the study. Embryo transfers were performed using the Edwards-Wallace catheter and graded as follows: Grade 1: easy, Grade 2a: difficulty in negotiating the cervical canal with or without blood on the catheter, and the necessity to use a hard catheter, Grade 2b: 2a plus necessity to use a volsellum, Grade 3: inability to negotiate the internal os. A Dilapan-S TM rod was placed intracervically under ultrasound control prior to starting gonadotrophin stimulation as an outpatient procedure (Day 4,5 of the period). The rod was left in situ for a period of 4 hours. All patients were given antibiotic prophylaxis. Chi-square and Fisher exact test were used when appropriate.Results: Dilapan insertion was considered easy in 42 patients, difficult in 11 and not possible in 1 patient. The procedure was well tolerated. Of the 54 patients who originally had grade 2a, 2b or grade 3 transfer, 43 patients (79.5%) had subsequent easy embryo transfer. Of the 37 patients who originally had a grade 2a transfer, Dilapan insertion did not improve the subsequent ET grading in 9 (16.5%) of those patients, nor did it improve the ET grading in the one patient out of 10 who originally had a grade 2b embryo transfer. Of the 7 patients who originally had a grade 3 transfer (1.8%) only 1 patient (1.8%) showed no improvement in the subsequent embryo transfer grading. The difference was statistically significant. Thirty patients managed to conceive giving a clinical pregnancy rate of 55%.Conclusions: Cervical dilatation using hygroscopic dilators in patients with cervical stenosis is an effective outpatient procedure leading to an easier embryo transfer and improved pregnancy rate.Supported by: none. Objective: To assess the value of cervical dilatation with hygroscopic cervical rods (Dilapan-S TM) in patients with cervical stenosis prior to starting gonadotrophin stimulation. Design: retrospective study. Materials/Methods: 54 patients undergoing embryo transfer after IVF or IVF/ICSI treatment that either failed to conceive after previous difficult embryo transfer, or were noted to have cervical stenosis at the time of the mock embryo transfer, were included in the study. Embryo transfers were performed using the Edwards-Wallace catheter and graded as follows: Grade 1: easy, Grade 2a: difficulty in negotiating the cervical canal with or without blood on the catheter, and the necessity to use a hard catheter, Grade 2b: 2a plus necessity to use a volsellum, Grade 3: inability to negotiate the internal os. A Dilapan-S TM rod was placed intracervically under ultrasound control prior to starting gonadotrophin stimulation as an outpatient procedure (Day 4,5 of the period). The rod was left in situ for a period of 4 hours. All patients were given antibiotic prophylaxis. Chi-square and Fisher exact test were used when appropriate. Results: Dilapan insertion was considered easy in 42 patients, difficult in 11 and not possible in 1 patient. The procedure was well tolerated. Of the 54 patients who originally had grade 2a, 2b or grade 3 transfer, 43 patients (79.5%) had subsequent easy embryo transfer. Of the 37 patients who originally had a grade 2a transfer, Dilapan insertion did not improve the subsequent ET grading in 9 (16.5%) of those patients, nor did it improve the ET grading in the one patient out of 10 who originally had a grade 2b embryo transfer. Of the 7 patients who originally had a grade 3 transfer (1.8%) only 1 patient (1.8%) showed no improvement in the subsequent embryo transfer grading. The difference was statistically significant. Thirty patients managed to conceive giving a clinical pregnancy rate of 55%. Conclusions: Cervical dilatation using hygroscopic dilators in patients with cervical stenosis is an effective outpatient procedure leading to an easier embryo transfer and improved pregnancy rate. Supported by: none.

Fertilization and early embryology: The prognostic value of successful in-vitro fertilization in subsequent trials

A retrospective study comparing in-vitro fertilization (IVF) results in patients with previous successful trials versus new IVF patients was designed with the objective of evaluating the prognosis in both groups. Patients were divided into two groups: group A, 22 patients with previous conception in IVF trials; and group B, 235 new IVF patients. All patients had tubal factor as the only cause of infertility and were stimulated by a standard protocol of gonadotrophin-releasing hormone agonist and human menopausal gonadotrophin. The pregnancy rate in group A (64%) was significantly higher than in group B (19%). In group A, 77% of the patients had three or more grade 1 embryos per transfer as compared with 16% in group B. In group A, 95.5% of patients had easy embryo transfer as compared with 61.2% in group B. The results of the study demonstrated that patients with previous IVF pregnancies have a significantly higher pregnancy rate compared with the control group. The improved pregnancy rate is due to the higher quality of embryos and the higher percentage of easy embryo transfers.