Watch the webinar on the topic of “IVF & Embryo transfer - how important is it to prepare a woman for transfer?
What’s the proper procedure of preparing the endometrium for embryo transfer?” Our guest speaker was Dr. Constantino Dino Demetroulis, a Director at theBiogenetic center for Human Reproduction in Greece. He is also an experienced Obstetrician and Gynaecologist with a subspecialty in Human Reproduction, IVF and Reproductive Endocrinology.
Dr Dino was raised in a medical environment, spending a lot of time in his father’s lab, and later in the IVF unit that he had set up – Biogenetic for HR which was the first IVF center in Greece in 1984. Dr Demetroulis has gained his experience at University Hospitals in the UK, The Royal London Hospital, St Bartholomew’s Hospital and Newham General Hospital of London.
Dr Dino’s motto is:
A baby for every couple.
Preparation before an embryo transfer
It is widely understood that a healthy, top grade embryo is more likely to result in a positive pregnancy outcome, but is that really the case, or is it the endometrium which decides whether implantation will occur? In this webinar, Dr Dino Demetroulis, Director of Biogenetic Centre for Human Reproduction, Greece, discusses the importance of the embryo transfer, outlining the correct procedure and advising how patients can prepare themselves to receive their incredibly special cargo.
Since the birth of the first IVF baby in 1978, in vitro fertilisation has been a great support to infertile couples. Over the last 40 years tremendous advances have been made, yet the knowledge surrounding the embryo transfer still remains uncertain, leaving fertility specialists to regularly question how they can work with patients to fully create the most conducive environment for implantation.
On average, the embryo is circa 60-80% responsible for implantation, with the endometrium counting for around 20-40%.
Whilst this figure is indeed less, it is still a major determinant in providing a successful outcome following IVF. It is therefore imperative that the body is properly prepared and that the procedure is performed correctly.
Embry transfer – the most important stage of an IVF
The embryo transfer is the final yet most crucial stage in the IVF process.
By this point couples have been though numerous investigations, tests, money and anxiety, whilst waiting for results and a diagnosis. Drugs have been administered, ovarian stimulation has taken place, followed by surgery to collect the eggs, fertilisation and the cultivation of those hugely valuable embryos. It has been a long journey for patients to reach this last step; a procedure that only takes between a couple of seconds to a couple of minutes. It is essential that nothing goes wrong during this shortest part of the treatment.
The three greatest factors, which are known to affect pregnancy rates, are the embryo quality, uterine receptivity and transfer efficiency.
However, within these determinants are numerous variables which can either have a positive or negative effect on the outcome. These include; the day of transfer, the transfer medium, catheter choice and placing of the embryo/s in the uterine cavity; all aspects heavily linked to the transfer process.
Embryo transfer – how to make it right
Dr Demetroulis outlines the most significant considerations, he believes, affect embryo transfer success. Transfers must only be carried out by experienced personnel
under ultrasound guidance. In his opinion, a soft type of catheter is usually best, and there should be no blood, in the catheter, following the procedure. It is also advisable for vaginal swabs and tests to be conducted before the transfer to check for any infections
. The placing of the catheter is also of high importance as it must not touch the uterine fundus; if contact is made this can cause the uterus to contract, which may lead to a rejection of the embryo. Ideally, transfers are atraumatic (free from any trauma), with an absence of pain or bleeding.
Endometrium comes from the Greek words Endo (inside) and Metra (uterus), it is the host of the embryo and the place where life grows, develops and lives until birth.
During pregnancy, the glands and blood vessels, in the uterine lining
, grow, increasing in size and number. Vascular spaces fuse, becoming interconnected and forming the placenta which, once a pregnancy is fully established, supplies oxygen and nutrition to the baby.
Implantation does not just happen at any time during a woman’s menstrual cycle, it can only take place during a specific timeframe, which is medically referred to as the window of implantation. During this window, the uterus is at maximum receptivity. To establish an endometrium which is optimal to receive and accept an embryo, several specific determinants, such as hormonal or immunological factors, need to coincide.
Endometrial receptivity and uterine lining
Endometrial receptivity can be assessed via ultrasound, hysteroscopy (biopsy) and hormonal receptors, checked through blood and uterine analysis.
ERA (Endometrial Receptivity Array) testing can also help infertility specialists understand further receptivity information, especially in patients whose cycles have repeatedly failed following the transfer of a good quality embryo. By using a small sample of endometrial tissue, the ERA test can help medical teams establish the best day for transferring the embryo.
Endometrial thickness also plays a role in helping to achieve a successful pregnancy outcome.
Dr Demetroulis explains that a woman’s uterine lining should be between 8-12mm, advising that thickness improves blood flow to the uterus whilst also providing a suitable place for the embryo to implant.
With IVF one approach does not suit all and it is the same when preparing the uterus; the endometrium is complicated. Within the body there are around 20,000 protein coding genes, which are expressed in human cells, circa 70% of these are found within a normal endometrium, finding one treatment to fit everyone is impossible. Doctors must ensure they have fully investigated the patient’s medical history, looking at what previously went wrong and trying differing regimens to find the most optimal treatment protocol for everyone.
When preparing for an embryo transfer it is important that the female is regularly scanned. Conditions such as OHSS, endometrium polyps, uterine fibroids or a thin endometrium
can all have an adverse effect on implantation. For patients suffering from any of these issues, then a freeze all cycle may be the most beneficial option. In women who have suffered from recurrent implantation failure then medical teams might also want to check for hydrosalpinges. This is when the fallopian tube/s become inflated with water. If the fluid passes down into the uterus it has the potential to affect the embryo. Fallopian tubes can be drained of any liquid which could hinder implantation.
Doctors should discuss all available options with their clients who, in turn, must never be afraid to ask any questions or challenge medical teams. The aim of every fertility specialist is ultimately to make every couple happy, and they should never be offended by patients who question.
So what can patients do to prepare the endometrium and aid implantation?
Dr Demetroulis explains that, in all honesty, the answer is variable and individualised to each woman. There are many myths surrounding implantation and, whilst the internet can be a great source of information, it is also a confusing place. Mothers-to-be should take vitamins, such as folic acid and vitamin b alongside their clinic prescribed medications, and not be afraid to use all types of treatments available, such as acupuncture or reflexology. Body shape has an impact on pregnancy and therefore patients should ensure they are neither under or overweight. Finally, couples should remain positive and let Mother Nature take over; for couples not undergoing IVF, they do not even think about the endometrium or implantation, yet natural pregnancies do happen.
The goal of any IVF cycle is to achieve a successful pregnancy to live birth and, in order to accomplish this, it’s important to choose a well-experienced and caring team; neither gynaecologists or embryologists nor nurses can make a pregnancy happen on their own; it’s imperative that clinics work together. Medical staff also need to recognise that every patient and every cycle is unique. Whilst there will always be similarities no two situations are ever the same. Infertility specialists should look at all the varying parameters so that they can do the best for each couple.
From his own experience, Dr Demetroulis has seen successful pregnancy outcomes from lower quality embryos, advising that chances are chances, percentages are merely a number and it’s the pregnancy test which tells patients whether they have been successful, not the statistics.
You may also be interested in reading: How to prepare for IVF Embryo Transfer, before and afterwards – Patient’s perspective