Ultrasound guidance during embryo transfer: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To summarize the current evidence on the effect of using ultrasound (US) guidance during embryo transfer (ET). METHODS: In this systematic review, we included randomized controlled trials examining the effect of the use of US guidance during ET; data from studies using the same catheter type in study arms were not pooled with the results from studies that used different catheter types. RESULTS: Twenty-one studies were included in the quantitative analysis: 18 compared 'US guidance' with 'clinical touch', of which one was subsequently excluded from the quantitative meta-analysis owing to a lack of available data, three studies compared transvaginal US guidance with transabdominal US guidance, and one study compared 'hysterosonometry before ET' with US guidance. Comparison of the use of US guidance with clinical touch, in studies that used the same catheter type in the study arms, indicated a benefit of using US guidance during ET on the rates of live birth (relative risk (RR), 1.48 (95% CI, 1.16-1.87)), based on two studies involving 888 women with moderate-quality evidence, and on the rates of clinical pregnancy (RR, 1.32 (95% CI, 1.18-1.46)), based on 13 studies involving 3641 women with high-quality evidence. However, when comparing the use of US guidance with clinical touch in studies that used different catheter types, the results suggest that using US guidance during ET has no effect on the rates of reproductive outcome: live birth (RR, 0.99 (95% CI, 0.83-1.19)), based on one study involving 1649 women with moderate-quality evidence; clinical pregnancy (RR, 1.04 (95% CI, 0.89-1.21)), based on five studies involving 2949 women with moderate-quality evidence. The estimates for the rate of miscarriage and for the other identified comparisons were imprecise. CONCLUSIONS: The available evidence suggests that there is a benefit of using US guidance during ET. However, both US-guided transfer and clinical touch should be considered acceptable, as the benefit of US is not large and should be balanced against the increased cost and need to change the catheter type. More studies are required before conclusions can be drawn regarding the effect of other techniques on reproductive outcome.

Ultrasound for monitoring controlled ovarian stimulation: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the efficacy and safety of monitoring controlled ovarian stimulation (COS) using ultrasonography. METHODS: We performed a search in April 2013 for randomized controlled trials (RCTs). Studies that compared different methods for monitoring COS, including ultrasound assessment of follicles (alone or combined with hormonal assessment), in at least one group were considered eligible. RESULTS: The search retrieved 1515 records, six of which were eligible. Five studies were included that compared ultrasonography alone with ultrasonography and hormonal assessment (estradiol and/or progesterone) and one study compared 2D and 3D ultrasound monitoring. None of the included studies reported on live birth. Four of the five studies reported on clinical pregnancy (RR, 0.95; 95% CI, 0.78­1.16; n = 611); the confidence interval (CI) was somewhat wide, but allowed us to conclude that ultrasonography alone differs little from ultrasonography combined with hormonal assessment. Three studies reported on the number of oocytes retrieved (mean difference (MD), 0.8 oocytes; 95% CI, ­0.4 to 2.0; n = 474); the CI was somewhat wide and did not permit us to conclude whether ultrasonography alone is better than or similar to ultrasonography and hormonal assessment for this outcome. All five studies reported on ovarian hyperstimulation syndrome (OR, 1.02; 95% CI, 0.47­2.25; n = 725) and only one study reported on miscarriage (RR, 0.37; 95% CI, 0.07­1.79; n = 45); for these two outcomes, the CI was very wide and did not permit us to conclude whether ultrasonography alone is better, similar or less effective than ultrasonography combined with hormonal assessment. For the study comparing 2D and 3D ultrasound, the reported outcomes were clinical pregnancy (RR, 1.00; 95% CI, 0.58­1.73, n = 72) and the number of oocytes retrieved (MD, ­0.4 oocytes; 95% CI, ­3.6 to 2.9; n = 72); for both, the CI was very wide and did not permit us to conclude whether use of 3D ultrasound is better, similar or less effective than use of 2D ultrasound. CONCLUSIONS: Current evidence suggests that monitoring COS only with ultrasonography is unlikely to substantially alter the chances of achieving a clinical pregnancy and the number of oocytes retrieved is similar to that when monitoring with ultrasonography and hormonal assessment. For the other outcomes and comparisons, the available data are inconclusive. We believe that more studies evaluating the optimal procedure for monitoring COS are needed.