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Evaluating Factors Affecting the Success of Embryo Transfer Procedure of the Preimplantation Embryo in IVF

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Evaluating Factors Affecting the Success of Embryo Transfer Procedure of the Preimplantation Embryo in IVF NATIONAL AND KAPODISTRIAN UNIVERSITY OF ATHENS SCHOOL OF HEALTH SCIENCES DEPARTMENT OF MEDICINE PHYSIOLOGY LABORATORY MSc. MOLECULAR AND APPLIED PHYSIOLOGY Evaluating factors affecting the success of embryo transfer procedure of the preimplantation embryo in IVF ROUNGOU PINELOPI-CHRISTINA Biologist R. N. 20160442 ATHENS OCTOBER 2018 SUPERVISING COMMITTEE: Simopoulou Maria Assistant Professor, Physiology Laboratory, Department of Medicine (supervisor) Koutsilieris Michael Professor & Head of Physiology Laboratory, Department of Medicine Philippou Anastassios Assistant Professor, Physiology Laboratory, Department of Medicine 2 Contents Prologue .................................................................................................................................... 5 Abstract ..................................................................................................................................... 6 Dissertation purpose ................................................................................................................ 7 1 Introduction ...................................................................................................................... 8 1.1 Assisted Reproductive Technology ............................................................................ 8 1.2 In vitro fertilization .................................................................................................. 12 2 Importance of Embryo Selection prior to transfer ........................................................ 16 2.1 Day 0: Oocyte / Pre-zygote quality .......................................................................... 17 2.2 Day 1: Two-cell embryo (Zygote) quality ................................................................. 17 2.2.1 Pronuclear Scoring System .............................................................................. 18 2.2.2 Cytoplasmic Appearance at Pronuclear Stage................................................. 22 2.2.3 Time of First Cleavage ..................................................................................... 23 2.3 Day 2: Four-cell embryo quality .............................................................................. 24 2.4 Day 3: Eight-cell embryo quality .............................................................................. 25 2.5 Day 4-5-6: Morula & Blastocyst quality ................................................................... 27 2.6 SART Grading System .............................................................................................. 29 3 Embryo Transfer (ET) ...................................................................................................... 32 3.1 Preparation of the patient ....................................................................................... 32 3.2 Preparation of the catheter ..................................................................................... 35 3.3 Transfer of the embryos .......................................................................................... 37 3.4 Care of the patient .................................................................................................. 38 4 Variables affecting a successful Embryo Transfer ......................................................... 40 4.1 Embryo Quality ........................................................................................................ 40 4.1.1 Developmental stage ....................................................................................... 40 4.1.2 Frozen versus fresh embryos ........................................................................... 41 4.2 Physiological and anatomical factors ...................................................................... 42 4.2.1 Anatomy of cervix and uterus ......................................................................... 42 4.2.2 Endometrial receptivity and endometriosis .................................................... 45 4.2.3 Cervical stiffness and stenosis ......................................................................... 47 4.2.4 Psychological parameters and mental state ................................................... 48 4.3 Technical approaches .............................................................................................. 48 4.3.1 Catheters and Syringes .................................................................................... 48 3 4.3.2 Ultrasound guidance ....................................................................................... 54 4.3.3 Types of embryo loading and volume (catheter wash and check - reload) .... 56 4.3.4 Types of media employed for ET ..................................................................... 57 4.4 Overall Transfer procedure - performance ............................................................. 58 4.4.1 Number of embryos transferred ..................................................................... 58 4.4.2 Uterus position ................................................................................................ 59 4.4.3 Presence of air in catheter .............................................................................. 60 4.4.4 Fluid dynamics and pressure ........................................................................... 60 4.4.5 Transfer depth of embryo placement ............................................................. 62 4.5 Observations during ET procedure and their importance (mucus, blood, comfort, reload, use of tenaculum / obturator) ................................................................................ 62 4.5.1 Presence of mucus and blood in catheter ....................................................... 62 4.5.2 Difficulties during transfer process ................................................................. 63 4.5.3 Reload phenomenon ....................................................................................... 64 4.5.4 Uterine contractions by use of tenaculum / obturator ................................... 65 4.5.5 Patient’s bed mobilization ............................................................................... 66 5 Success rates following Embryo Transfer ...................................................................... 67 5.1 Parental age ............................................................................................................. 67 5.2 Frozen versus fresh embryos ................................................................................... 67 5.3 Embryo developmental stage .................................................................................. 68 5.4 Loading technique ................................................................................................... 69 5.5 Presence of air bubble in uterus ............................................................................. 70 5.6 Mobilization and bed rest after Embryo Transfer ................................................... 71 5.7 Healthy or ectopic pregnancy.................................................................................. 72 6 Discussion ........................................................................................................................ 73 6.1 Latest trends in Embryo Transfer ............................................................................ 73 6.2 Optimal practice and the need for a universal protocol ......................................... 76 6.3 Future prospects...................................................................................................... 81 6.4 Conclusions .............................................................................................................. 84 Summary ................................................................................................................................. 86 References ............................................................................................................................... 90 4 Prologue This thesis dissertation has been elaborated during my studies of the postgraduate program “Molecular and Applied Physiology” in the department of Medicine at National and Kapodistrian University of Athens. It was conducted in the laboratory of Physiology in 2018. First of all, I would like to express my gratitude to my supervisor, Assistant Professor Maria Simopoulou for the assignment of the present thesis, the valuable opportunity she gave me to collaborate with her as well as her support during this project. I particularly thank her PhD student Anna Rapani for her valuable help that she provided to me at all stages of this dissertation until it was completed. I would like to express my gratitude to Professor Michael Koutsilieris and Assistant Professor Anastassios Philippou for participating as members of the thesis committee. Finally, through the depths of my heart I want to thank my parents, my family and my friends for their love, constant support and encouragement in continuing my studies and fulfilling my dreams and goals. 5 Abstract Embryo transfer (ET) is a critical step in the success of in vitro fertilization, where embryos generated into a laboratory are placed in the uterus. The aim of ET is to gently locate the embryos to the endometrial cavity, to a location where implantation has more probabilities to occur. Over the past 30 years the procedure of ET has remained nearly unchanged. Despite the major improvements in embryo culture, genetic screening, embryo selection and embryo cryopreservation,
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