This ppt concentrates on optimising IVF results by sharpening the OPU and ET techniques.

1. OPTIMISING OPU and ET
Dr Mangala Devi
Director, SMILE BABY IVF

2. Definition
Oocyte Pick-up (OPU) is an ultrasound-guided technique in which
oocytes are aspirated using a needle connected to a suction pump.

3. Optimising OPU
Several steps:
1. Measues Prior to OPU
2. Equipment and consumables
3.OPU preparation
4. OPU procedure
5. Post-procedure care
6. Associated pathologies and cautions during OPU
7. Complications and risks
8. Future developments
9. Training and competence
10. Quality assurance and performance

5. Prior to OPU
Pelvic Ultrasound –
performed before starting an ART treatment
(i) to decide the ovarian stimulation protocol,
(ii) to determine anatomical abnormality/
malposition of the ovaries/accessibility of ovaries
(iii) to assess ovarian placement and
ovarian/follicular accessibility after previous
surgery (gynaecological surgery for myomas,
endometriomas, adhesions
(iv) detection of recent lesions(endometrial
abnormalities /ovarian cysts)
(Grimbizis et al., 2016)

6. Prior to OPU
• Pre-OPU 3D Ultrasound and Doppler :helpful , familiarize with the anatomy
of the patient, and to prevent (vascular) complications.
• Time frame to perform the US:
discretion of the clinician.,
within 4-6 months from start of ovarian stimulation,
shortened in cases of significant conditions (endometriosis, surgery, specific
symptoms).
T WG recommends a baseline US closer to the OPU to highlight any difficulties or
reconfirm previous findings.

7. Prior to OPU
Vaginal infection screening (by taking a vaginal sample for bacteriological examination) :
In asymptomatic patients :unclear
In symptomatic women: recommended to perform specific testing for cervical and
vaginal infections and take appropriate actions.
Patient medical history - depends on local regulations of pre-operative management.
No evidence with regard to preventing complications.
use of medications important - use of blood thinning agents (aspirin and others)
Relevant previous surgeries, and any relevant disease or deficit of coagulation
factors.
Information provision and informed consent
Verbal and written information, according to local templates, explaining procedure
and risks

8. EQUIPMENT AND CONSUMABLES
• Equipped as per European standards/local regulations
The following equipment for OPU should be available on a
sterile operation table:
• sterile small gauzes
• disposable /reusable speculum for cervical examination
and to visualize any bleeding site
• test tube warmer and heating block should be available
(at 37°C),
• culture medium for flushing should be prepared and ready
at 37°C.
• Additional equipment and consumables : ovary clamps,
sponge holder, vaginal surgery equipment, (absorbable)
sutures.
• Resuscitation equipment: reversal anesthetic drugs, a
prepared kit for anaphylactic shock treatment and oxygen

9. EQUIPMENT AND CONSUMABLES
Ultrasound system and transducer:
• High frequency TVS transducer(5-8MHZ) TAS(2-6 MHZ)
• Regular software calibration
• Serviced as per manufacturers instructions
• Correlate measurements of auto follicular measurements with oocyte
maturity
• Appropriate disinfection Protocol for transducer
• Powder free transducer covers used,latex free covers used if patient allergic
• Avoid lubrication on outside of probe cover: gametotoxic,embryotoxic

10. EQUIPMENT AND CONSUMABLES
NEEDLE:
• Single lumen(17-18 G) used commonly ,
needle with edging preferred
• Double lumen: Used in smaller
follicles/where flushing is needed
• Transclucent tubing to visualize aspirated
fluid
• Needle guide disposable or sterilized
• Check needle patency and aspiration
ability before opu
Suction Pump:
100-200mmHg used
Maintain constant pressure as changes
cause turbulence

12. Basic principles of the OPU technique
Position of patient: patient places her buttocks at the edge of the gynaecological couch and the operator is standing or sitting in
between the patient’s abducted and supported legs.
Transvaginal transducer : technique of holding, Placing the transducer parallel to hand of the operator, L-R orientation ,Top-Down
orientation of transducer
Avoid contaminating the needle tip of the probe when introducing it in the vagina, by keeping the needle inside the needle guide
until ready to pierce the vagina
Position of ovary should be lined up to the most accessible position on the screen. The transducer should be against the ovary
(through the vaginal wall).
Follicular Aspiration: Carefully insert the needle inside the follicle. Needle should be inserted in the middle of the ovary to prevent
the ovary from moving and needle to cause injury to adjacent organs. The echogenic tip of the needle should be identified during all
maneuvers. The needle guide seen on the monitor can facilitate safer insertion as it projects where the needle tip will progress. - It is
advised to keep the needle in the centre of the follicle during aspiration and observe the follicle walls to collapse around the tip. - The
needle tip markers must be observed at all times as it is manoeuvred within the ovaries and into each follicle; the needle tip should
never be advanced if not visible.
Follicular Aspiration Aspirate the follicular fluid containing the oocyte/cumulus complex by application of suction. - The walls of the
follicle collapse as the fluid is aspirated; before moving the needle to the next follicle, the operator should ensure that all the follicular
fluid is withdrawn. - The needle can be advanced into an adjacent follicle or withdrawn to the edge of the ovary; realignment is
needed to advance into another follicle. Minimize as far as possible repetitive puncture through the vaginal wall. - Avoid lateral
movements of the needle to reduce the risk of vascular damage. - Do not move the transducer with the needle in the advanced
position. - Puncture all follicles, especially if there is a high risk of ovarian hyperstimulation syndrome (OHSS). - Flush the needle
between the two ovaries to avoid any potential blockage caused by blood clots.

13. Post-procedure care
• After the procedure, patients should remain in bed at the centre for recovery (about 2 hours, or
less if the procedure was performed with local anesthetics only).
• General status, abdominal distension, blood pressure and heart rate should be monitored by a
nurse.
• In cases of significant pain or abdominal distension, a blood analysis and/or an ultrasound scan,
should be performed before discharge to check for potential intra-abdominal bleeding.
• Patients should be able to eat, drink, and pass urine before discharge.
• Check awareness, orientation, and respiratory rate.
• A written information leaflet about post-care procedures, complications, and a 24 h emergency
number should be provided.
• In patients with hematoma, bleeding or infection after the OPU, antibiotic coverage is
recommended.
• Procedures should be in place for when severe complications occur, including hospital admission
arrangements, specialist responsibility and continued care.
• Provide patients with a leaflet with written information and a 24 h emergency number.

15. Complications
Infection:
• from vaginal puncture leading to contamination from vaginal bacteria into intra-peritoneal space
• presence of latent pelvic infection /pelvic endometriosis /teratoma : contributing factors
Bleeding:
usually unremarkable
• Haemoperitoneum after OPU :defined as a haemoglobin reduction >2g/day, an increase in the pelvic free fluid >200 ml or a calculated blood loss
>500 ml. –
Paralysis:
After para-cervical block, a transient leg paresis may develop, which usually disappears after 2-4 h.
Resuscitation protocol:
The IVF centre should have proactively established policies with respect to how to provide patient resuscitation and access to surgical theatre in case of
internal bleeding or other organ injury in a haemodynamically unstable patient (safety standard).
Safety standard:
OPU video recording help to identify reasons for complications ,improvement of OPU technique with respect to ultrasound settings for clear imaging
and types of manoeuvres during oocyte aspiration.
Registration of complications:All severe complications should be registered according to local requirements. It is recommended that more details on
severe complications are gathered from the EIM data collection.
• (Kelada and Ghani, 2007).

17. Competency Criteria for OPU
• the number of oocytes collected : >7
• the number of ovarian punctures :<3
• the ratio of number of oocytes retrieved to the number of follicles aspirated
(80%)
• Any complications from the procedure, in the short or long term
• the duration of the OPU procedure < 45 mins
• Oocyte recovery rate:% of follicles >15mm diameter yielding COC (85-100%)
• Oocyte maturity rate:%of recovered oocytes at Metaphase 2 (75-90%)
• No.of OPU’s :30 under supervision and 50 independently
• 250 nos : expert!!
Dessolle et al., 2014, Panayotidis, 2017

18. Quality assurance and performance
• Documentation : clear ,readable, OPU description with images and
results (fx. how many oocytes obtained, difficulties during procedure,
information for future audit,about the equipment)
• Key performance indicators analysis : undertaken at least once per
year in the IVF centre.
• Annual audit of OPU :at least once a year. Done by external auditor/
quality managers /members of same team observing each other

19. Recommendations for future research in OPU
Further research is recommended on the following aspects of OPU:
• Value of FBC or any additional test (microbiology) before OPU for
prevention of complications
• Value of antibiotic prophylaxis in low-risk patients
• Value of flushing to increase number of eggs retrieved
• Effect of different aspiration pressures on oocyte yield
• Complications rates related to the OPU performance under sedation
versus general anaesthesia.

20. Future developments
Doppler studies :
• useful to detect vascular areas in case of doubt in 2D ultrasound imaging
• differentiate from hypo-echogenic areas that look alike as superficial follicles
versus iliac or para-ovarian vessels
Artificial intelligence
• based on US features, patient profile and biochemical metrics information, can be
used as a predictor of how much the follicle grows in the next few days.
• predicting the growth of poor responders’ follicles
• Another application could be to classify the follicles during the process of growth
and use this information in OPU and embryo selection for transfer.

21. Associated pathologies /cautions during OPU
• Management of hydrosalpinx : removal or clipping before OPU (Song et al., 2017).
If discovered during OPU: first option should be oocyte or embryo cryopreservation
• Patients with potential infectious risk (HIV, hepatitis) : managed in an isolated circuit / in specialized centres
to avoid cross-contamination.
• In women with endometriosis : Endometriomas should not be aspirated during OPU,
puncture of endometriomas avoided to prevent contamination of follicular aspirate and reduce the risk of
intra-abdominal infection
• Dermoid cysts/Teratoma: should not be punctured during OPU, increases risk of PID and peritonitis. If an
endometrioma or a hemorrhagic follicle is inadvertently punctured, the needle should be immediately
withdrawn and flushed with media, and the collecting tube should be changed.
• Borderline ovarian tumours: unclear whether ART procedures are associated with an increased risk of
recurrence
• PCOS: Increased risk for bleeding has been suggested in lean women
Benaglia et al., 2008, Kasapoglu et al., 2018, Moini et al., 2005, Villette et al., 2016).

22. Optimising Embryo Transfer

23. Factors affecting Embryo Transfer Outcome
Before ET
Embryo selection and Grading
Choice of catheter
Patient relaxation before procedure
Role of Ultrasound and Mock embryo
transfer
Damage to endometrium
Experience of Clinician
During Embryo Transfer
Position of Patient during ET
Technique of ET
Cervical mucous Removal
Ultrasound Guided ET
Type of ET media
Time Interval
Embryo placement in Uterine cavity
Post Embryo Transfer
Bed Rest
Sexual Intercourse
Medications post transfer

24. Embryo grading and selection
• Morphological grading of embryos
• Time lapse techniques
• AI selection
• Embryo metabolomics:
Resp rate,glucose consumption,NO levels,Aminoacid turnover
• Delaying transfer from day2/3 to day 5/6

25. Choice of catheter
Ideal : soft catheter : Co axial variety
avoids any trauma to endocervix / endometrium
malleable ,pliable to negotiate canal
AND smooth tip, nontraumatic
Co axial variety: outer rigid sheath minimally used ,stop short of the internal
os
Rigid catheter : special cases
needed to pass through resistance in internal os.
essential that these rigid catheters are malleable

26. Role of Ultrasound
• Measuring and evaluating cervico- uterine angle,
length and direction, diagnosing any fibroids
encroaching or distorting cervical canal
• To choose the most suitable catheter for the embryo
transfer.
• To discover any unanticipated difficulty in entering the
uterine cavity,
• Assessment of Endometrial thickness(>8mm,Triple line,
Volume> 2.5ml)
USG guided ET : Beneficial!!

27. Damage to endometrium
Endometrial disruption : negative impact
Due to
• Bleeding in uterine cavity
• Inflammation of endometrial lining
• Plugging of ET catheter
• Retention of embryos
• Initiation of Uterine contractions and expulsion of embryos

28. Experience of Clinician
• Clinician's skill and acumen: Non traumatic transfer
• Clinician’s Experience : Influences OUTCOME

29. Embryo Transfer Technique
• Patient Counselling: Details of Fertilisation rate, available embryos and selected embryos
• Pre Procedure Requirement:
• Preprocedure medication
• Fluid intake
• Ultrasound for bladder status
• Procedure:
• Insertion of Cusco's Speculum and visualisation of cervix
• Cleaning of cervical mucous
• Ultrasound visualisation of cervical canal and Uterine cavity
• Insertion of Outer Sheath loading Embryos in Inner Catheter
• Deposition Of Embryos into Uterine cavity
• Inspection for retained Embryos and re transfer

30. Factors During Embryo Transfer
• Position of patient:
Lithotomy preferable, Bladder partially full
• Technique:
Poor embryo transfer technique leads to 30% of all failures
Gentle and atraumatic, painless,
Lack of blood, mucus ,endometrial cells at catheter tip
Cusco’s speculum recommended
Avoid use of Vulsellum to hold cervix
Avoid touching uterine fundus
Gentle manipulation, avoid pushing Cervix
Karande et al., 1999; Hearns-Stokes et al., 2000),

31. Cervical Mucous Removal
Cleaning mucous at cervix before ET with sterile applicator or
aspiration of mucous with syringe
• Prevention of entanglement of embryos
• Prevent expulsion of embryos
• Cervical mucus culture tested positive in 71% of cases : reduced
pregnancy rates stick to the catheter and inadvertently remove the
embryo during catheter withdraw

32. USG Guidance During ET
USG guidance: Preferred cf Touch Technique
• Visualise echogenic tip
• Determine exact site of embryo deposition
• Ensures that embryo column and Air bubble interface not displaced after ET
• Visualize the cervical uterine angle for negotiation of catheter and minimise
trauma

33. Time interval
• Interval between catheter loading and the discharge of the
embryos into the cavity affected IVF outcomes(Temp ,humidity
,PH changes outside Incubator)
• Delay >120 seconds: decrease in pregnancy rates from 31.6%
to 19.1% and a decrease in implantation rate from 15.9% to
9.4%.
• Load catheter only when patient is positioned, cleaned ,draped
and Ultrasound focussed on uterine cavity
• extra care and time should be given to embryo transfer, which is the
most critical step in IVF.

34. Volume and type of transfer media
Media type:
• High Protein content, physiological concentration,
• Use of Hyaluronan /fibrin sealants in transfer media
Air Bubble technique:
Embryos transferred bracketed between 2 air bubble columns
• Bubbles mark position of embryos in catether
• Protects against inappropriate placement,prevents entanglement to
mucous plug
• Madani et al. injected an additional amount of air after the embryo
fluid column was injected. This extra air injection resulted in a
significant improvement in implantation and pregnancy rates.

35. Deposition of Embryos in Uterine cavity
• Ideal site: Mid cavity gives better
implantation
• Maximum Implantation Point (MIP) :
intersection of two imaginary lines
formed by extending the fallopian tube
course inside uterine cavity

36. Proper delivery of the embryos inside the uterine
cavity
• Ensure embryo transfer catheter has passed the internal
os and entered the uterine cavity
( test :rotate the catheter 360°. If it recoils, it means that
it is curved inside the cervical canal)
• Ensure alignment between the catheter and utero–
cervical canal : gently curving the outer sheath of the
catheter will overcome this problem in most cases
• Straightening the utero–cervical angle can be achieved by
a full bladder
• Facilitating entry of catheter by gently maneuvering the
vaginal speculum

37. Withdrawal of Catheter
Wait for the release of embryos vs Immediate withdrawal
No differences in the pregnancy rate between withdrawal of the catheter immediately
after embryo deposit or after a 30 s wait
If the fluid flows in a laminar way forward from the catheter tip toward the fundus, as
visualized by ultrasound, pregnancy rates are improved.
The effect of forward laminar flow resulted in a 55.9% pregnancy rate, compared with
28.6% without forward laminar flow
Martinez et al., 2001,Wisanto et al., 1989; Al-Shawaf et al., 1993).
Rapid withdrawal may create a negative pressure and result in the withdrawal of
the embryos
R.T. Mansour, M.A. Aboulghar.,Human Reproduction, Volume 17, Issue 5, May 2002, Pages 1149–1153

38. Rapid vs Slow Injection
• percentage of embryos shrunken/ collapsed increased in the
rapid injection group.
• rates of apoptosis in the embryos of the rapid injection group
were increased.
• embryo trauma may be related to the rapidity of injection
• rapid injection may lead to embryo placement issues and
possibly promote ectopic pregnancies
care should be taken to inject the fluid as slowly as possible

39. Difficult vs Easy transfer
• Tomás et al. evaluated 4,807 ETs with regard to the degree of difficulty.
Easy or intermediate transfers resulted in a 1.7-fold higher pregnancy rate
than difficult transfers (P<.0001; 95% confidence interval 1.3–2.2)
• Avoiding difficult ET is important to optimize clinical outcomes, and ultrasound
guidance seems to be a key adjunct toward this goal

40. Fresh vs Frozen transfer
• Impaired endometrial receptivity during fresh IVF cycles due to
the controlled ovarian hyperstimulation medications and the
altered hormonal stimulation of the uterine lining
• Pelkonen et al. demonstrated that for frozen embryo transfers there
was a lower incidence of preterm birth, low birth weight, small for
gestational age infants, and a reduced need for intensive neonatal
care

41. Bed rest and Sexual Intercourse
Controversial subjects
• Evidence for bed rest: No benefit cf
Immediate ambulation
Anything more than a short period of bed rest
is without proven benefit
Sexual intercourse:
No need to avoid. No difference in outcome
Individualizing recommendations for patients’
preferences and anxiety is better

42. Adjuvant compounds to impact the uterus
• Tocolytics, prostaglandin synthetase inhibitors, and the use of
vaginal P as a uterine relaxant
Oral adminisration of piroxican 1 to 2 hours before ET significantly improved
pregnancy and implantation rates
• Impact of low-dose glucocorticoids before ET : indicate no
beneficial effect
• Use of Antibiotics, Aspirin ,sildenafil: Not recommended