Embryo Transfer: Practical Tips to Get Ready for Prime Time

Objectives To review the evidence for best practices in contemporary embryo transfer technique Patient preparation Type of catheter Ultrasound guidance To go beyond the evidence and provide practical advice for the transition from fellowship to independent practice There was a little girl BY HENRY WADSWORTH LONGFELLOWThere was a little girl,             Who had a little curl, Right in the middle of her forehead.             When she was good,             She was very good indeed, But when she was bad she was horrid.

The Evidence Avoid difficult transfers - ~1.7 higher pregnancy rate with easy or intermediate transfers What’s a “difficult transfer? “I know it when I see it” Time consuming Require additional instrumentation (stylet, firmer catheter, tenaculum) May induce uterine contractions Blood on catheter tip How do you avoid difficult transfers? Some are inevitable Many are preventable with proper prior planning KISS: May all your transfers be “Easy” transfers Difficult = “definition of obscene”, “Oh shit” moment aka time consuming, extra instrumentation, cause discomfort Mains L & Van Voorhis B, Fertil Steril, 2010

Trial Transfers Consider a trial or mock ET Prior to stimulation May not reflect conditions at time of actual ET Allows for modifications prior to time of ET (dilation, cervical stitch, etc) At time of oocyte retrieval Does not appear to interfere with receptivity1 Immediately prior to ET May induce uterine contractions May use “after load” technique Katariya KO, et al, Fertil Steril, 2007

Soft versus Firm Embryo Transfer Catheters – a Meta-Analysis of RCTs Favors Firm Favors Soft 10 Randomized Trials Various catheters included 4,141 patients total Significantly favors soft catheters OR = 1.39; 1.08 – 1.79 Abou-Setta et al Hum Reprod 2005 20:3114–21

Ultrasound Directed versus Clinical Touch Transfers – a Meta-Analysis of Clinical Pregnancy Rates

Ultrasound Guided vs Clinical Touch Outcome Measure Number of Cycles Effect Size Favors Live Birth Rate 615 1.78 (1.19-2.67) Ultrasound Guided Ongoing Pregnancy Rate 2,531 1.49 (1.25-1.78) Clinical Pregnancy Rate 2,731 1.46 (1.23-1.72) Implantation Rate 5,270 1.47 (1.25-1.72) Adverse Results Need Instrumental Assistance During Transfer 3,982 0.61 (0.50-0.74) Higher need with Clinical Touch Catheter Tip Bloody 2,613 0.53 (0.40-0.70) More common with Clinical Touch Retained Embryos 3,002 0.41 (0.16-1.01) Marginal more common with Clinical Touch Abou-Setta et al Fertil Steril 2007; 88:333–41

Advancing the Outer Sheath Past the Internal Os May Reduce Pregnancy Rates Above the Os Below the Os Retrospective Observational Guide position relative to the os Below n=218 Above n=190 Outcomes reduced when guide passed beyond the internal os % Abelmassih et al Fertil Steril 2007; 88:499 –503

Where in the Endometrial Cavity Should the Embryos be Placed? Location , Location, Location…

Location of Embryo Transfer within the Endometrial Cavity Impacts Clinical Outcome Prospective, sequential N=666 No difference in distribution of Age Embryo developmental state Outcomes improved with lower transfer Frankfurter et al Fertil Steril 2004; 81:1273-7

Impact of the Provider Doing Transfer on IVF Pregnancy Rates 619 patients, 854 embryo transfers, 10 clinicians Transfer MD assigned by rotation without regard to patient type or prognosis Clinical pregnancy rate varied significantly High of 54.3% Low of 17.0% No measurable differences in embryo quality Hearns-Stokes et al Fertil Steril 2000; 74:80-6

Does Provider Experience Impact Embryo Transfer Success Does Provider Experience Impact Embryo Transfer Success? How to Prepare During Fellowship? Figure 1 Mean fellow clinical pregnancy rates for the first 100 ETs before (blue circles) and after (red crosses) implementation of the IUI training requirement. The median pregnancy rate among attending physicians is noted as a marker of proficiency. N=14,887 Shah D et al Fertil Steril 2013; 100:386-91

How to Prepare During Fellowship? Watch different providers perform ETs Not just those perceived to have top rates Perform abdominal ultrasounds Set up the ET yourself Perform many, many IUIs with Wallace catheter Perform IUIs and mock transfers with ultrasound guidance Do as many real transfers as possible ~44% of fellows perform no Ets And they all got jobs

No Pressure, But… The Embryo Transfer is the culmination of: Years of attempting pregnancy for this couple Weeks of diagnostic infertility testing Dozens of injections and office visits for follicular ultrasounds and blood work Days of hard work by a dedicated clinical embryology team to ensure that this embryo has the best chance of implanting Selection out of cohort of embryos to find the best one And now the outcome is all in your hands

What do you do with this stuff? Beyond the Evidence Your first day at your new practice What do you do with this stuff?

Beyond the Evidence Your first day at your new practice What type of speculum do you prefer? What type of catheter do you like to use? How do you like your bladders filled? How do you prep the cervix? On what side do you like to receive the catheter? Do you like the catheter tip bent by the embryologist? How do you hold the catheter? What do you tell the patient about her embryos? How do you know how you’re doing with ETs?

How do you avoid difficult transfers

ET: Practical Tips for Success 90% of the game is half mental Yogi Berra, MLB Catcher and Manager

Develop a technique Have a comfortable grip that gives you control and flexibility Know your team Embryologists Sonographer

ET: Practical Tips for Success Have a routine…and stick to it

ET: Practical Tips for Success Have a routine…and stick to it

ET: Practical Tips for Success Have a routine…and stick to it No distractions

ET: Practical Tips for Success Have a routine…and stick to it No distractions Have a battle plan and an exit strategy

ET: Practical Tips for Success Have a routine…and stick to it No distractions Have a battle plan and an exit strategy Be comfortable

How’m I Doing?: Track Your Outcomes Track your rates Make notes regarding: Difficult ET Blood on ET catheter Retained embryos

Track Your Outcomes

Track Practice Outcomes

Conclusions The Embryo Transfer is an essential technique for ART practice Data suggests improved outcomes with: Reduction in difficult ETs Soft catheters Ultrasound guidance Practice as much as possible Be comfortable and relaxed Have a plan Preparation can prevent difficult transfers

Track your ET outcomes and be critical of yourself Take Home Point Track your ET outcomes and be critical of yourself