The influence of the depth of embryo replacement into the uterine cavity on in vitro fertilization outcome.

OBJECTIVE: The aim of our study was to investigate the influence of the depth of embryo replacement into the uterine cavity on the implantation rate after embryo transfer carried out under transabdominal ultrasound guidance. METHODS: This was a prospective observational study at the St Lazar Hospital, Skopje; spisan patients with an indication for IVF or ICSI according to departmental protocol underwent controlled ovarian hyperstimulation followed by IVF/ICSI and embryo transfer. The highest quality embryos were selected for transfer, with quality being assessed based on cell number and number of cytoplasmic fragments. On the day od ET under direct transabdominal ultrasound guidance, the transfer catheter was advanced through the endocervical canal into the lower uterine segment. Immediate identification of the catheter tip was essential to minimize motion of the catheter and avoid any impact on the endometrium. The transfer catheter then was advanced to a defined distance from the uterine fundus, up to the point estimated for transfer: 10 +/- 2.5 mm and 15 +/- 2.5 mm respectively in A and B group. This measurement was verified by using the calipers prior to injection of the embryos. RESULTS: In total, 106 patients, aged 24-42 years were included in the study. The patients were divided into two groups according to the distance between the tip of the catheter and the uterine fundus at the time of embryo deposition in the cavity: group A: 10 +/- 2.5 mm; group B: 15 +/- 2.5 mm. Of the patients studied, 47.16% were less than 35 years old, with only 11.3%% more than age 40 years. The majority (66.9%) of patients had either none or one previous transfer. In only 3.7% transfers was blood noted on the catheter tip; and 77.4% of transfers were rated as easy compared to 5.6% rated as difficult. The remaining transfers were moderately difficult. The mean number of embryos transferred per cycle was 2.32. A mean E2 levels on HCG day was 2120 pg/ml. Overall clinical pregnancy were 37.7%. There were not significantly differences between the two groups in term of embryo transfer characteristics (full bladder, ease of transfer, use of tenaculum, bleeding). Our results show that there was not significantly differences between two groups in term of gonadotropin ampoules administered (30 +/- 12.2 in group A vs. 3633 + 868 in group B); Estradiol levels on the day of HCG day (1897 + 761 in group A vs 29.2 +/- 10.8 in group B), mean of oocytes retrieval and embryo transferred ( ET) (8.5 + 6.7 vs 10.9 +/- 6.9; 1.9 +/- 1.1 vs 2.3 +/- 1.2 respectively in group A and B), and grade of ET. Analysis of our results demonstrated that pregnancy rate is significantly influenced by transfer distance from the fundus where the pregnancy rate decreases from 46.2% in group B to 28.8% in group A (p < 0.05). There was not significantly difference in abortion rate between the two groups. CONCLUSION: In conclusion, our results suggest that depth of embryo replacement inside the uterine cavity may influence the pregnancy rates and should be considered as an important factor to improve the success of IVF cycles.

Assessment of uterine artery and arcuate artery blood flow by transvaginal color Doppler ultrasound on the day of human chorionic gonadotropin administration as predictors of pregnancy in an in vitro fertilization program.

OBJECTIVE: To investigate whether success rates of IVF/ICSI could be predicted by using the Color Doppler technique by measuring the uterine artery and arcuate artery pulsatility (PI), resistance (RI), and velocity (Vs) indices on the day of hCG injection. METHODS: This was a prospective observational study at the St Lazar Hospital, Skopje; 106 patients with an indication for IVF or ICSI according to departmental protocol underwent controlled ovarian hyperstimulation followed by IVF/ICSI and embryo transfer. Using Color Doppler in the two-dimensional (2D) mode, flow velocity waveforms were obtained from the ascending main branch of the uterine artery on the right and left sides of the cervix in a longitudinal plane and arcuate arteries, before they entered the uterus. The PI, RI and peak systolic velocity (PSV) of the uterine arteries and arcuate arteries were calculated electronically when similar consecutive waveforms of good quality were obtained and results were compared between patients who conceived and those who did not. RESULTS: In total, 106 patients, aged 24-42 years were included in the study. The patients were divided into two groups according to successful outcome, defined as pregnancy and failure of implantation, where no pregnancy was detected. A total of 40 pregnancies resulted; a crude pregnancy rate was 40/106 (37.7%). There were no significant differences between either group in patients' age, type and duration of infertility; basal levels of FSH, LH and E2; number of gonadotropin ampoules used for ovulation induction; number of retrieved oocytes and number of transferred embryos. No cycle was canceled after initiation of gonadotropin stimulation. In our results, there were statistically significant lower mean uterine artery PI and RI in the pregnant group than in the non-pregnant group (P < 0.05). Arcuate artery PI value was lower in the pregnant group than in the non-pregnant group, but this did not reach statistical significance. Peak systolic velocity (Vs) values in both the mean uterine artery and arcuate artery were higher in the pregnant group than in the non-pregnant group; however, the difference was not statistically significant. CONCLUSION: Vascular impedance was calculated with PI, RI, and Vs values, among which PI was found to be the most important. Optimal uterine receptivity can be accomplished by reduced vascular resistance and increased blood flow, which will improve pregnancy success. We suggest the use of transvaginal color Doppler ultrasonography to measure the blood flow in uterine arteries and arcuate arteries before hCG in IVF cycles.