2. Embryo Transfer: Practical Tips to Get Ready for Prime Time

3. 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.

4. 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

5. 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

6. 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; – 1.79
Abou-Setta et al Hum Reprod :3114–21

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

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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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?

18. How do you avoid difficult transfers

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

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

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

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

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

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

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

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

27. Track Your Outcomes

28. Track Practice Outcomes

29. 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

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