1-Embryo Transfer in Human-Hendro Pramono

7/28/2019 1-Embryo Transfer in Human-Hendro Pramono

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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

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1-Embryo Transfer in Human-Hendro Pramono

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