The document discusses the embryo transfer technique in IVF cycles. It states that embryo transfer is the final and most crucial step, affecting pregnancy rates. Various factors like uterine receptivity, embryo quality, and transfer efficiency impact pregnancy outcomes. A gentle, atraumatic technique is emphasized, including mock transfers to check for issues like stenosis, as well as ultrasound guidance, minimal media, and careful catheter placement without touching the fundus. Problematic cervixes may require pretreatment like dilation. Overall the key is a gentle, controlled transfer process to avoid trauma.

1. Embryo loading & Transfer
Dr Aruna Saxena, MD (Obs & Gyn)
ART course for Embryologists , NUS ,Singapore
Director, Lifecare IVF , Gagan Vihar Delhi

2. Embryo Transfer Technique
• ET final & most crucial step of IVF cycle
• 80% of IVF reach ET but PR very low
• Variable affecting PR
• Uterine receptivity
• Embryo quality
• Transfer efficiency
± 30% of failure in ART is due to poor ET technique

3. • Significant differences in PR after the ET
performed by different clinicians
Hearn-Stokes, et al., Fertil Steril, 2000
• A poor embryo transfer technique often results
in embryo implantation failure
Schoolcraft et al., 2001

4. ET Technique: Literature review
• Englert et al.
Excellent Transfer ( 33.3% PR)
Bad transfers ( 10.5% PR)
• Mansour and colleagues
• Easy transfer (20% PR & 6.7% IR )
• Difficult transfer (4% PR & 1% IR)
• Tur-Kaspa et al. and Nabi et al., found no difference in
success between easy and difficult transfers

5. Essential features of ET in humans unchanged since described by Edwards
> 30 yrs ago
1. MOCK ET
2. Check for Full bladder, OHSS,
Fluid in cavity
3. Select embryos & put in
transfer plate
4. Cervical lavage
5. Placing outer catheter
6. Load inner catheter with
minimum media & air interface
7. Placement of tip
8. Eject embryos ,rotate 360
degree, withdraw catheter
9. Check for any retained embryos
10. Blood on catheter tip indicates
difficult transfer

6. 1.Trial Transfer
• Uterine cavity depth and direction
• Cervical stenosis , Cervical polyp/
fibroid
• Routinely performed 1 to 2 month
prior to the IVF cycle.
• RCT of 335 patients
NO trial transfer : Difficult ET in 50
(29.8%)
PR & IR were 13.1% and 4.3%
Trial transfer : Easy ET
PR&IR were 22.8% and 7.2%
Mansour et al

7. Trial Transfer :The Problematic Cervix
• Cervical stenosis OR acute angulation
between the Cx & the uterus
• Visser et al. : cervical dilatation two days prior to ET -
no pregnancies
• Groutz et al.: Cervical dilatation during OPU- EASY
TRANSFER but PR 2.5 %
Short interval not long enough for the endometrium
to recover from any trauma, inflammation, or
bacterial contamination induced by the dilation.

8. Trial transfer : Problematic Cx
• Abuscheikha et al. cervical dilatation prior to
initiating the treatment cycle : easier transfer and
improved PR
• Yanushpolsky et al.
36 women with h/o difficult entry
Pretreated with cervical dilatation, hysteroscopy,
and the placement of a 16-22 French Malecot
catheter for an average of 10 days
ET after 3 weeks to 3 months later. 32/ 36 women
had an easy ET

9. Problematic cervix at ET:
• Malleable stylet can be used to place the
outer sheath of a Wallace catheter past the
internal os. The stylet is then removed and the
inner clear catheter inserted.
• “Towako Procedure”: Transmyometrial
transfer

10. 2.Transfer medium: EMBRYO GLUE ?
• Albumin is a macromolecule traditionally used as the
main macromolecule in most culture media.
75%, 8%, and 2.25% of protein, no difference in
outcome
• Hyaluronic acid has a positive effect on PR and can
successfully replace albumin as a transfer medium
(Simon et al., 2003; Mahani & Davar, 2007)
• Replacing protein in the transfer medium with the
glycosaminoglycan hyaluronan , shown to
significantly improve outcome in the mouse model
(Gardner 1999)

11. 3. Cervical mucus on or in the catheter
A retrospective study analysing 1204 ET :
Retained Embryos when ET catheter contaminated
with mucus or blood.
Nabi, et al., Hum Reprod, 1997
Damage to the embryos
Improper embryo placement

12. Cervical mucus
• Visser (1993) found a decrease in pregnancy
rates from 20% to 3% when embryos were
retained.
• The embryos can stick to the cervical mucus
around the catheter and be dragged outside
during the withdrawal of the catheter.

13. Cervical Mucus
• Cervical mucus also a source of contamination of the
endometrial cavity and the embryos.
• Egbase et al. found cervical mucus to be culture positive in 71% of cases.
PR 29.6% in culture positive pt
PR 57% in culture negative pt
• Fanchin and colleagues : Positive cultures of the catheter tip in 51% of cases.
PR 24 % (Culture positive) vs 37% ( Culture negative)
IR 9% (Culture positive) vs 16 % ( Culture negative)

14. Cervical mucus
• Cervical lavage before
ET to remove all visible
mucus
– 55% pregnancy rate with
lavage
– 41% pregnancy rate
without lavage
Mac Namee

15. 4. Catheter Type
• The ideal embryo
transfer catheter should
be soft enough to avoid
any trauma to the
endocervix or
endometrium and
malleable enough to
find its way into the
uterine cavity

16. Catheter type
• Although stiff catheters and use of a
rigid outer sheath make catheter
placement easier, they may result in
more bleeding, trauma, mucus plugging
and stimulation of uterine contractions
• Soft catheters allow the tip to follow
the contour of the cervical and uterine
axis and minimize trauma to the
endometrium

17. Catheter type
• Pregnancy rate with different catheters
– Frydman 32%
– Wallace 19%
– TDT 19%
• Wisanto, et al., Fertil Steril, 1989
• Pregnancy rate with different catheters
– Frydman 31%
– Wallace 30%
Al-shawaf, et al., J Assist Reprod Genet, 1993

18. Catheter type
• 518 IVF cycles
– Soft catheter 36%
– Hard catheter 17%
• Wood, et al., Hum Reprod, 2000
• Pregnancy rate with different catheters
– Tomcat 35%
– Wallace 63%
– M-Wallace 69%
Schoolcraft, et al., 2003

19. 5. Loading of catheter: vol of transfer media
• A large volume (60 microliters) of transfer media and a large air
interface may result in expulsion of embryos into the cervix, on the
speculum, or adhere to the outside of the catheter .
• Meldrum: increase in PR& IR after reducing
the amount of air and the total transfer
volume
• CCRM a continuous fluid column of 30 microliters is used in a
Wallace catheter attached to a 1cc airtight syringe. The embryos
are loaded preferentially toward the tip of the embryo column
closest to the catheter opening

20. 6. Avoid Uterine contractions
• Fanchin et al. digitized five-minute ultrasound scans
frequency of myometrial contraction: 4.3 per
minute
• Decreased PR &IR with Increased UC
• High P4 on Day of ET, less uterine contractions

21. Uterine contractions
Tenaculum : Oxytocin release
Internal os : Prostaglandins release
When outer catheter pushed beyond
internal os (Fraser.1992)
Touching the fundus
UC progressively decrease as
One moves into the Luteal phase
success of day 5 blastocyst transfers
Lensy et al

22. Uterine contractions
• Lesny et al.-Mock ET with 30 microL of Echovist in 14 OD
Easy mock ET- No change in UC, and the contrast
remained in the upper uterus for 45 minutes.
Difficult ET- strong fundo-cervical UC, contrast
relocated from the fundus in 6/7 cases. Movement
toward cervix (4) & into the tubes (2)

23. 7.Placement of catheter tip
• Waterstone et al. :
• Clinician 1 :
fundus felt, and then withdrew 5 mm
PR 24% (33/137)
• Clinician 2
5 cm from the external os and
deposited the embryos without
touching the fundus.
PR 46% (45/98)
• Yovich et al. (35) and Nazari et al.
Fundus touched or embryos < 5 mm
from the fundus - ectopic gestation.

24. Pregnancy outcome according to the distance
between fundus an catheter tip
Coroleu et al.: Hum Reprod. 2002,17, 341-346
Pregnancy
outcome
Cath tip 10mm Cath tip 15mm Cath tip 20mm
PR 37.1% 48.6% 58.6%
IR 18.2% 28.6% 31.8%

25. 8. USG guided ET
• avoids touching the fundus
• catheter is beyond internal os in
cases of an elongated cervical canal
• directs catheter along the contour ,
avoiding disruption of the
endometrium & plugging of the
catheter tip with endometrium, and
the instigation of bleeding.
• Ancillary advantages: OHSS, Fluid in
the endometrial cavity
• full bladder straightens the cervical
uterine access and improving PR

26. USG guided ET : position of implantation
• Baba et al. evaluated 60 ET: 22 pregnancies & 32 GS
3D USG: GS in the area where the air bubble was seen
• Lideholm et al. small microspheres in a 50 μl fluid
column and performed Mock ET prior to Hysterectomy
Microspheres within 1 cm of site of deposition
These results emphasized that embryos
generally implant where they are deposited,
and therefore the importance of careful embryo
placement.

27. Ultrasound Guidance
• Better pregnancy rate
Wood, et al., Hum Reprod, 2000
Coroleu, et al., Hum Reprod, 2000
• No significant difference
Al-Shawaf, et al., J Assisted Reprod Genet, 1993
Kan, et al., Hum Reprod, 1999

28. 9. Transfer technique : properties of syringe
• Tested using MEA, not embryo toxic
• Squeezed in a controlled fashion: not to “pop" the
embryos with such force that they are damaged or
thrust into fallopian tube
• Degree of “recoil” , embryos reaspirated
Withdrawing the catheter 1 cm and injecting briskly
& maintain pressure on plunger to avoid
retrograde flow of transfer media by capillary
action

29. 10. Standing after ET
Woolcott and Stanger examined the effect of
standing immediately after transfer on the
movement of the embryo fluid column/air
interface.
• No movement was seen in 94% of cases,
• < 1 cm of movement was visualized in 4%
• > 4 cm of movement was witnessed in only
2% of cases.

30. Bedrest
• In a study that had > 1000 cycles the results strongly
suggested that bedrest was not necessary following
embryo transfer
Sharif, et al., Fertil Steril, 1998

31. CONCLUSION : Gentle atraumatic transfer
1.Mock ET /Trial transfer
2.Cervical lavage
3.Soft catheter
4.Avoid volsellum
5.Outer catheter just at internal os
6.Meticulous loading , less media
7.Placement of catheter tip under
USG guidance
8.Transfer speed
9.SET ( Cochrane review 2005)
10.Treat problematic Cx in
previous cycle

32. ADDRESS
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