Embryo transfer and Luteal phase support
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1 Embryo transfer and Luteal phase support PATCHARADA AMATYAKUL, M.D. DEPARTMENT OF OBSTETRICS AND GYNECOLOGY FACULTY OF MEDICINE NARESUAN UNIVERSITY
2 Embryo Transfer
3 Embryo Transfer Final step of IVF, but received little attention Transfer technique important determinant of IVF success Goal of a successful ET is to deliver the embryos atraumatically to a location in uterus where implantation is maximized
4 Difficult transfer Ease of Embryo Transfer Time consuming Require a firmer catheter Cause discomfort Involve additional instrument : tenaculum High pregnancy rate in ease transfer
5 Ease of transfer Philips. Difficult embryo transfer or blood on catheter and assisted reproductive outcomes: a systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology 2013.
6 Presence of blood on the transfer catheter Philips. Difficult embryo transfer or blood on catheter and assisted reproductive outcomes: a systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology 2013.
7 Trial or Mock Transfer Before starting ovarian stimulation, on the day of OPU or immediately before the actual ET To take additional precaution Significantly reduced incidence of difficult transfer during the actual ET
8 Ultrasound guided transfer Clinical touch disrupt endometrium and cause uterine contraction Transabdominal approach Pregnancy rate is significantly higher with u/s guided transfer Location cm from uterine fundus
9 Ultrasound image of embryo transfer Mains. Optimizing the technique of ET. Fertil Steril 2010.
10 Transcervical transfer Clinician s experience Clean vagina and cervical mucus Use soft catheter and tip or the entire catheter can be visualized on ultrasound Volume loaded ~ ul Withdraw the catheter slowly Minimized negative pressure
11 Transcervical transfer Minimized trauma during transfer Use of hyaluronan (glycosaminoglycan) enriched transfer medium may improve pregnancy rate Use minimum amount of time for procedure Bed rest after embryo transfer no significant difference in pregnancy rate
12 Assessment of embryo quality Invasive embryo selection PGD (polar bodies, blastomeres, trophectoderm) Non-invasive embryo selection Embryo morphology Blastocyst culture Time-lapse monitoring Metabolomics
13
14 Luteal phase support Progesterone from corpus luteal is crucial for endometrial receptivity Luteal insufficiency after the use of GnRH agonist and antagonist Luteal phase support significantly improves IVF outcome
15 Protocols of luteal support hcg Progesterone Intramuscular Vaginal gel, capsule Oral Progesterone + Estrogen Progesterone + GnRH agonist
16 Comparison of hcg vs placebo or no treatment, outcome 5 OHSS Favour placebo Favour hcg Linden. Luteal phase support for assisted reproduction cycles. Cochrane Database of Systematic Reviews 2011.
17 Comparison of progesterone VS hcg, outcome 1 Live birth rate. Favour progesterone Favour hcg
18 Comparison of progesterone VS hcg, outcome 5 OHSS Favour progesterone Favour hcg Linden. Luteal phase support for assisted reproduction cycles. Cochrane Database of Systemati Friday, Reviews August 23,
19 Pharmacokinetics of progestrorone supplementation Various formulations of progesterone Serum progesterone is higher after IM injection painful, sterile abscess, eosinophilic pneumonia, allergic reaction, inconvenience High endometrial progesterone levels after vaginal progesterone administration vaginal irritation, vaginal discharge
20 First uterine pass effect Alam. Luteal phase support. Reproductive BioMedicine Online 2001.
21 Distribution of luteal phase supplementation Vaisbuch. Progesterone support in IVF: is evidence-based medicine translated to clinical practice: A worldwide web-based survey. Reproductive BioMedicine Online 2012.
22 Comparison of progesterone VS placebo or no treatment, outcome 1 live birth rates Favour placebo Favour progesterone Linden. Luteal phase support for assisted reproduction cycles. Cochrane Database of Systematic Reviews 2011.
23 Favour placebo Favour progesterone Linden. Luteal phase support for assisted reproduction cycles. Cochrane Database of Systematic Reviews 2011.
24 Comparison of progesterone VS progesterone + estrogen, outcome 2 clinical pregnancy rate
25 Comparison of progesterone VS progesterone + GnRHa, outcome 1 live birth rate Linden. Luteal phase support for assisted reproduction cycles. Cochrane Database of Systematic Reviews Favour P Favour progesterone + GnRH agonist
26 Luteal phase support hcg increases risk of OHSS Progesterone administration is effective, but the route is depended on clinicians and patient s preference P + E protocols is still controversial P + GnRHa may improve pregnancy rate Duration of support is varied from 14 D 10 wk
27 Pregnancy is a real miracle of life
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