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7/28/2019 1-Embryo Transfer in Human-Hendro Pramono
1/22
11/21/20
TRANSFER EMBRIOpada manusia
Hendro Pramono
Divisi Fertilitas Endokrinologi ReproduksiBag Obstetri Ginekologi - FK Unair
Assisted Reproduction
1. Patient Selection
2. Pre-Treatment Preparation
3. Ovarian Stimulation
4. Monitoring of Ovarian Response
5. Oocyte (Egg) Retrieval
6. Sperm Collection and Preparation
7. In Vitro Fertilization
8. Embryo Transfer
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ET
87,5% of all patients who underwent OPU had embryos
available of for transfer 21,1% conceived
Tremendous advances have been made in ART but basic
method of ET remains essentially unchanged
(SART survey, 1992)
Function of ET
Timing of ET Sinchronicity
To safely place cultured embryoswithin the uterine cavity
State of embryosdevelopment
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ET Procedure 1
In the operating theater under sterile condition
Identity of patient is checked
The embryologist explains about the embryos:
Fertilization & cleavage of embryos
Quality and number to be transfered
ET Procedure 2
Lithotomy
Speculum, lubricated with saline solution vagina
Cervix is exposed gently and any vaginal and cervical secretion
are gently removed, moistened with medium
Dummy / Mock ET catheter:
Distorted canal can be identified
Road map delineated in anticipation of actual ET
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ET Procedure 3
The embryos are identified by the embryologist and scored
and their details are entered into the log
Those embryos that are to be transferred are placed into a
drop of medium
A Frydman embryo transfer catheter is used for transfer
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ET Procedure 4
The catheter + 1ml tuberculin syringe and flushed through
with medium.
The embryo(s) are drawn up into the already charge catheter
The catheter is taken through to the theater and passed to the
surgeon
The catheter is gently maneuvered through the cervical canal
and into the uterus
ET Procedure 5
The tip of catheter can be placed in the mid or low-mid
uterine cavity
5-5,5 cm from the external cx os or
2 cm below uterine fundus
When operator is confident that catheter is properly placed,
the embryologist or surgeon can slowly & gently inject the
embryo into uterus
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ET Procedure 6
Catheter is left in position for a few moments, then gently -
slowly removed
Catheter is returned to the lab, checked to ensure that
embryo have not been retained
Factors affecting success ofembryo transfer
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Number of Embryo to Transfer
No embryos
transferred
% Live Birth Rate
Pertransfer (
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Blastocyst Culture Transfer vs embryo
Transfer
High-order multiple preg
Preg rate probably not increased
Should all embryos be grown to blastocyst? NO!
Variability in blastocyst culture success
Lower preg rates with frozen/thaw blastocysts
Culture success rate 30 - 60%
ET complications
1. Difficult transfer
2. Mucus present on the catheter after transfer
3. Multiple attempts to correctly place the catheter
4. Blood present on the catheter after transfer
5. Embryos remaining in the catheter after transfer
Hearns R, Hill J , Scott L, Segars J , Alvero R, 1999 TheInterNational Council on Infertility Information Dissemination, Inc.
The Five embryo transfer complications:The Five embryo transfer complications:
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The frequencies of 5 complications (290 ET):
Difficult Transfer
Mucus on the catheter after transfer
Multiple attempts to place the catheter
Blood on the catheter after transfer
Retained embryos after transfer
22%
18%
14%
9%
4%
Hearns R, Hill J , Scott L, Segars J , Alvero R, 1999 TheInterNational Council on Infertility Information Dissemination, Inc.
Factors affecting success of ET
1990 - 2000:
2 Chocrane systematic reviews
5 meta-analysis
34 RCT
1) Pre-transfer factors
2) Transfer factors
3) Post-transfer factors
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PRE-TRANSFER
1. Trial (dummy, mock) transfer
Trial ET:
determines the most suitable catheter & avoids unexpected difficult & failed ET
(Mansour et al, 1990)
Clinical Preg Rate
Clinical Implantation Rate
Trial
No Trial
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2. The best day for embryo transfer
Day-2 vs day-3 ET:
(Oatway et al, 2004, Chocrane library)
Day-2 ET
Day-3 ET
vs
clinical PR
improvement in live birth??
2. The best day for embryo transfer
Day-5 vs day-3 ET
(Sallamet al, 2003; metaanalysis)
Day-5
Day-3
NO advantages overThe clinical PR, IR, ongoing PR &The incidence of multiple preg
Early ET
Blastocyst culture
Little difference inoutcome parameters
vs
Early ET vs Blastocyst culture
(Blake et al, 2004, Chocrane library)
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3. Cervical infection
Cervical infection diminishes the PR & IRs
(Sallamet al , 2003; meta-analysis)
Positive culture
Negative culture
PR: 21 %
PR: 38.4 %
vs
4. Use of antibiotics
The prescription of Amoxicillin + Clauvulanic acid from the
day of OPU to 6 days
Peikrishvili et al, 2004
Antibiotis does not improve the implantation rate
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5. The use of fibrin sealant
Felchtinger et al,1992:
Fibrin sealant Ectopic preg: completely avoided
Fibrin sealant Advantageous only in elderly women (39-42 y)
NO advantageous in younger patients (39-42 y)
Ben-Rafael et al, 1995:
Fibrin sealant
A type of surgical glue that is made from human blood-clotting proteins,and that is used during surgery to control bleeding
The journal Thrombosis and Haemostasis 1995
Ready to apply in minutesRemains manipulable for a short time after application
Solidifies relatively quickly
Usable
High internal bonding strengthHigh surface adherence strengthEnhances clot formationEnhances wound healingEnhances tissue regeneration
Effective
Components and degradation products would pose nodangers, such as viral disease transmission
Safe
CHARACTERISTICSATTRIBUTE
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6. Embryo Glue Medium
Embryo Glue medium is an ET medium containing highamount ofhyaluronon
Karimian et al (2004), Enginsu et al (2004), Mardesic et al (2004)
Hyaluronon in thae culture media Has no benefit on PR or IR
7. Bladder filling:
(Mitchell et al, 1989)
With a filled bladder
Without a filled bladder
No significant differences in difficultiesvs
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8. Vigorous flushing of the cervical canal
(Sallam et al, 2000)
Flushing culture medium before ET Do not improve the clinical PR
9. Type of ET catheter:
(Wisanto et al, 1989)
The Frydman catheter
The Wallace catheter
The TDT catheter
PR: 32%/ET
PR: 19%/ET
PR: 9%/ET
The choice of catheter did not affect PR
(Ghazzawi et al, 1999)
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9. Type of ET catheter
(van Weering, 2002):
K-soft 5000 catheter
TDT catheter
vs
PR
Cook catheter
TDT catheter
vs Similar PR
(Karande et al, 2002; Saldeen et al, 2003; Mcllveen et al, 2004):
10. Transmyometrial vs transcervical ET:
(Groutzet al,1997)
Transmyometrial ET(elective)
Transcervical ET
vs
No benefit
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TRANSFER
Value of UGET:
Flow of transfer medium (jet phenomenon) detectedduring UGET
(Cruickshank et al, 2003)
Laminar flow
Non Laminar flow
PR
Obstructed flow
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2. Site of embryo deposition
(Nazari et al, 1993)
Embryos were deposited2 cm below the uterine fundus
1 cm below the uterine fundus
IR
The mid-cavity technique
The deep-cavity
(Coroleu et al, 2002)
IR
EP
3. Difficult ET:
Difficult ET diminish the P & IR significantly
(Meta-analysis, Sallam et al, 2003)
difficult transfers
easy transfers
PR 22.3%
PR 31.0%
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POST-TRANSFER
Slow withdrawal of the ET catheter
PR: NO statistically significant
Slow withdrawal
immediately after ET
30 second delay
Martinz et al, 2001
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2. Mechanical pressure on the portiovaginalis
of the cervix:
Applying gentle mechanical pressure on the portiovaginalis of
the cervix using the vaginal speculum during & after
transferring the embryo
Significantly improved the clinical P & IR
(Mansour, 2004)
Bed restfollowing ET
24 h bed rest after ET 20 min rest period
Not associated with a better outcome
Prolonged bed rest does not influence the IR
Botta & Grudzinskas,1997
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CONCLUSION
Pregnancy rates are significantly increasedwhen
1. Trial transfer
2. Soft ET catheter
3. UGET
4. Deposition of the embryo 2 cm below the uterine fundus
5. Gentle mechanical pressure on the portiovaginalis cervix
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Thank You
for your attention