1. Prof. Aboubakr M Elnashar Benha University Hospital
EMBRYO TRANSFER
Prof. Aboubakr M Elnashar
Benha University Hospital
Aboubakr Elnashar

2. TIMING The final, yet crucial step in IVF.
Meticulous technique is essential for IVF success.
TIMING
ET is usually performed 2-5 d after OR
Aboubakr Elnashar

3. 2. ET CATHETERS Different types
varying in length, diameter, stiffness, memory
Aboubakr Elnashar

4. ET Catheters
Labotect
Wallace
Cook
Aboubakr Elnashar

5. Thick hollow plastic tube (catheter ) with
1. OUTER SHEATH
Thick hollow plastic tube (catheter ) with
bulb (Guide catheter)
stopper; and
markings.
Bulb:
helps the doctor to bypass the blind endocervical crypts which line the cervical canal and can cause the tip of the catheter to get trapped.
Aboubakr Elnashar

6. fits snugly within the outer sheath. made of metal:
2. OBTURATOR
fits snugly within the outer sheath.
made of metal:
allows the doctor manipulate the outer sheath: can negotiate the curvature of the endocervix.
3. INNER SHEATH
soft tube
with markings at distal end of the tip.
The embryologist loads embryos into this sheath and then hands this to the doctor.
Aboubakr Elnashar

7. 3. TECHNIQUE Before ET Instruct patient come fasting
{as a precaution in case the need for G A}.
2. Inform patient:
fertilization rate
number of available embryos
number of embryos selected for the transfer.
ET is a simple procedure.
If she is much stressed: G A.
Aboubakr Elnashar

8. US picture of the uterus Dummy ET
3. Revise:
US picture of the uterus
Dummy ET
length
direction of the uterus
cervico-uterine angulation
4. Lithotomy position:
-Cervix is visualized using Cusco’s speculum.
-Vaginal vaults are cleaned using tissue culture media & sterile gauze.
-The cervical mucus at the external os is aspirated gently & repeatedly using a 1 cm3 syringe.
Video: ER
Aboubakr Elnashar

9. B. Transfer I. Standard technique
The loaded ET catheter is introduced through the cervix to pass the internal os under US guidance.
gently advance inner sheath in the mid-uterine cavity& stopped from 1–2 cm short of the fundus.
3. {Some patients experience suprapubic heaviness& discomfort}.
After 1-2 min, when this complaint disappears, the embryos are ejected slowly
4. Catheter is left in situ for sec
5. Pressure is kept on the plunger of the syringe while slowly withdrawing the catheter out avoiding negative pressure.
Aboubakr Elnashar

10. The catheter is checked for any retained embryos.
C. After ET
The catheter is checked for any retained embryos.
If found, retransfer is done immediately.
2. Bed rest:
30 min
12 H: Not necessary
Video: ER1
Aboubakr Elnashar

11. II External sheath 1st – ET= afterload technique=
(Adrienne et al, 2005)
2 -step catheter insertion
(Esteve , 2014)
Under US guidance:
outer sheath of (the labotect) ET catheter is passed, just beyond the internal os.
2. The inner sheath is loaded by the embryologist
who assist the physician in threading the inner sheath into the external sheath.
The inner catheter is slowly advanced by the physician
embryos are deposited 1.0 cm from the fundus (mid uterine cavity).
Aboubakr Elnashar

12. 2- step catheter withdrawal After 5–10 s:
(Esteve, 2014)
After 5–10 s:
Soft catheter removed first (pressure on the syringe plunger maintained) while outer sheath withdrawn past internal os
Laboratory check
2. Rigid outer sheath removed and checked
One step catheter withdrawal
(Adrienne et al, 2005)
The catheter is gently rotated and removed (with keep the plunger of the catheter depressed until it had been completely removed from the cervix) over 15 s.
Video: ER after load
Aboubakr Elnashar

13. Advantages improve CPR by useful in centers
Facilitating the ease of ET
Decrease the interval time of the procedure
Decrease the usual contamination of ET catheter with mucous and/or blood.
useful in centers
training physicians to perform ET with no additional cost on the patient.
video
Aboubakr Elnashar

14. 4. FACTORS AFFECTING SUCESS
4. FACTORS AFFECTING SUCESS
Before ET
1. Embryo Selection
ESET necessitates proper embryo selection
Selection
Morphological criteria: graduated embryo score
(Fisch et al).
2. Other criteria:
Early cleavage
Prolonging embryo culture to the blastocyst stage
PGD
Aboubakr Elnashar

15. D 2 or 3 (early) Vs D5 or 6 (late): Blastocyst transfer
Significantly higher CPR
(Guerif et al., 2004; Levitas et al., 2004).
{Improved embryo selection and uterine receptivity}
Aboubakr Elnashar

16. diminishes the P & IRs significantly.
3. Cervical infection:
diminishes the P & IRs significantly.
PR for patients with positive cultures: 21%
patients with negative cultures: 38.4%
(Sallam et al , 2003; meta-analysis)
Aboubakr Elnashar

17. 4. Use of antibiotics: does not improve IR
from the day of OR up to 6 days
(Amoxicillin + Clauvulanic acid)
does not improve IR
Aboubakr Elnashar

18. 5. Choice of the Catheter The ideal ET catheter soft
{avoid any trauma to endocervix or endometrium}
malleable
{find its way through the cervical canal into the uterine cavity}.
The outer rigid sheath should be minimally used to stop short of the internal cervical os.
If the outer sheath is introduced first, it will convert a ‘‘soft’’ catheter into a ‘‘stiff’’ catheter.
ET catheter passing through the internal cervical os can initiate contractions.
Soft catheters: higher PR compared to firm catheters.
Aboubakr Elnashar

19. 6. Mock (dummy, trial) ET AIM
(Sharif et al.1995)
AIM
Length of the uterine cavity& cervical canal
Direction of the uterine cavity& cervical canal
2. Cervico-uterine angulations.
3. Choose the most suitable catheter
4. Discover any difficulty:
pinpoint external os,
cervical polypi or fibroids
anatomical distortion of the cervix from previous surgery or congenital anomaly.
Aboubakr Elnashar

20. Before the start of the IVF cycle (1month)
Timing:
Before the start of the IVF cycle (1month)
At the time of start of ovarian stimulation
At the time of OR
Immediately before the real transfer.
The timing does not affect FR, IR or PR.
Performing a mock ET at the time of OR, 3 to 5 days before ET, does not have a deleterious effect on the endometrium
(Katariya et al, 2007)
Aboubakr Elnashar

21. Diminishes the incidence of difficult ET 2. Increases IR & PR
uterine length and position changes with ovarian stimulation challenging the role of trial transfer
(Henne et al., 2009)
RVF uterus at mock ET will often change position during the actual procedure.
USG mock ET during the real ET is a better method of judging the direction of the uterine Axis.
(Shamonki et al).
Value:
Diminishes the incidence of difficult ET
(Mansour et al.)
2. Increases IR & PR
Aboubakr Elnashar

22. 7. ET Medium Fibrin sealant added to the ET medium:
non-significant improvement in PR
benefit in elderly patients only
Fibrin glue (EmbryoGlue)
prior to ET:
significant improvement in IR & PR
Aboubakr Elnashar

23. 8. Ultrasound Before ET Aim
1. Length of uterine cavity& cervical canal
2. Cervico-uterine angle.
(a) no angle
(b) small angle (<30)
(c) moderate angle (30–60)
(d) large angle (>60)
Aboubakr Elnashar

24. 3. Fibroids: 4. Uterine anomalies.
encroaching on the uterine cavity or distorting the cervical canal
4. Uterine anomalies.
5. Contents of the endometrial cavity
e.g. newly developed hydrometra in patients with hydrosalpinges:
Aspiration of the uterine fluid did not help
{its rapid reaccumulation}
Cryopreservation of the embryos for future transfer after removal of the hydrosalpinges
Aboubakr Elnashar

25. 6. Endometrial thickness
<8 mm: implantation cannot take place
>14mm: hinder implantation. However, not confirmed
7. Endometrial pattern
Homogeneous: predict an adverse outcome
Triple-line: associated with conception.
8. Endometrial volume by 3D
<2.5 mL on the day of ET: poor likelihood of implantation.
Aboubakr Elnashar

26. 9. Full Bladder : straightening’’ the uterus: increases PR. Not in RVF
Aboubakr Elnashar

27. 10. Vigorous flushing of the cervical canal with culture medium
: increases PR.
not confirmed
Aboubakr Elnashar

28. 11. Uterine Relaxing Substances
Progesterone:
starting on the day of OR. not improved PR compared to starting on ET day.
NSAIDs: .
10 mg piroxicam (feldene), 1-2 h before ET:
significant improvement of I& PR
Sedation with 10 mg valium:
30 min-1 h before ET:
did not make any difference.
Aboubakr Elnashar

29. 1. Position of the Patient
B. During ET
1. Position of the Patient
knee-chest position Vs dorsal position:
No significant difference in PR or EP (3.5 Vs 5.4%)
Aboubakr Elnashar

30. 2. Analgesia &Anesthesia
No significant difference in PR
Acupuncture:
significantly higher PR than those who did not.
Hypnosis:
significantly higher IR& PR
However not confirmed
Aboubakr Elnashar

31. 3. US-Guided ET Value: Catheters with echodense tips
Uterocervical angle immediately prior to ET: bend the catheter accordingly: minimize trauma to the cervical canal&/or the endometrium.
Visualize the tip of the ET catheter& the exact site of embryo deposition
Confirm that the embryo-associated air bubble is not displaced after ET.
Aboubakr Elnashar

32. Rotating the catheter by 360 C:
6. Ensuring that catheter has passed internal os & not kinked or curved:
How to know?:
Rotating the catheter by 360 C:
If it recoils: it is curved inside the cervical canal.
:Gently maneuver the vaginal speculum (the degree of opening& how far it is pushed inside): facilitate entering the catheter
Aboubakr Elnashar

33. 7. Gentle& Atraumatic Technique Even in introducing the speculum
{avoid unnecessary pushing of the cervix}.
Difficulties during ET:
Difficulty in negotiating the cervical canal
Necessity of using a volsellum
Presence of blood after ET.
Only the presence of blood on or in the catheter decreased PR& IR significantly.
(Alvero et al.)
{ET can cause rapid pressure fluctuations in the transferred liquid}: transfer the embryo gently with minimum ejection speed {avoid exposing the embryo to the steep pressure gradient}.
(Grycrouk et al, 2011)
Aboubakr Elnashar

34. Difficult ET diminish the PR (22.3 Vs 31%) & IR significantly
Difficult Vs easy ET
Difficult ET diminish the PR (22.3 Vs 31%) & IR significantly
(M A, Sallam et al, 2003).
{Trauma to the endocervix& endometrium}.
Murray et al.
used hysteroscopy: no clear association between perceived difficulty of transfer& amount of endometrial damage.
Aboubakr Elnashar

35. 8. Avoid Touching the Uterine Fundus
Place the catheter 1.5 cm from the fundus.
Coroleu et al.
IR was significantly higher when the embryos were deposited 2 cm below the uterine fundus compared to when deposited 1 cm below the fundus.
Aboubakr Elnashar

36. 9. Site of Embryo Deposition
=The relative position of the catheter tip within the uterine cavity
Depositing the embryos in the miduterine:
distance between the tip of the catheter and the uterine fundus at transfer 1.5–2 cm:
Better IR
lower incidence of EP
Measure the cervical canal& uterine cavity during dummy ET or by US
Aboubakr Elnashar

37. 10. Time Interval between Embryo Loading & Discharging
Matorras et al.
The longer: the lower PR & IR
An interval >120 sec (2 min): poor prognosis.
Aboubakr Elnashar

38. 11. Withdrawal of the Catheter After ET
Wait
60 sec after introducing the catheter into the uterus before ejecting the embryos
slowly inject
60 sec before catheter withdrawal
{uterus can stabilize}
slowly withdraw
Aboubakr Elnashar

39. C. After ET
Bed Rest
1 h Vs 24 h
No statistically significant difference in PR
(21.5 Vs 18.2%)
IR was significantly higher
(14.4 Vs 9%)
Immediate ambulation Vs 1-2 h
No adverse effect on PR
{Endometrial cavity is a potential space.
ET catheter only separates the opposed endometrial surfaces
Once the catheter is removed, the endometrial surfaces re-oppose}.
Aboubakr Elnashar

40. 2. Sexual Intercourse during the peritransfer period Vs abstinence
PR was not significantly different
IR was significantly higher
Aboubakr Elnashar

41. (Buckett Fertil Steril
(Buckett Fertil Steril. 2006; Abou-Setta et al Reprod Biomed Online 2007; Brown et al Cochrane Database Syst Rev 2010; Abou-Setta et al. Cochrane Database 2009; Derks et al Cochrane Database Syst Rev. 2009; Bontekoe et al Cochrane Database 2014; Cheong et al Cochrane Database Syst Rev. 2013; Craciunas et al Fertil Steril 2014; Gaikwad et al Fertil Steril 2013)
Aboubakr Elnashar

42. You can get: This lecture from: My scientific page on Face book:
Aboubakr Elnashar Lectures.
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My clinic, 3 Althawra St. Almansura
ABOUBAKR ELNASHAR