Improving embryo transfer technique is crucial in the field of assisted reproductive technology (ART) as it significantly influences the success of in vitro fertilization (IVF) procedures. A well-executed embryo transfer is vital for the optimal implantation of embryos, leading to a higher likelihood of a successful pregnancy. Here are several key strategies to enhance the embryo transfer technique: Firstly, proper training and skill development for the fertility specialist or clinician performing the procedure are essential. Training programs that emphasize hands-on experience and guidance from experienced practitioners contribute to proficiency in embryo transfer. Continuous professional development ensures that practitioners stay updated on the latest advancements in the field. Secondly, utilizing ultrasound guidance during embryo transfer enhances precision. Real-time visualization enables the clinician to accurately navigate the catheter through the cervix and deposit the embryos in the ideal location within the uterine cavity. This minimizes the risk of trauma and increases the chances of successful implantation. Maintaining a relaxed and comfortable environment during the procedure is equally important. Studies suggest that minimizing stress and anxiety in both the patient and the clinician can positively impact the success of embryo transfer. This involves effective communication with the patient, addressing any concerns, and ensuring a supportive atmosphere in the clinic. Optimizing the timing of embryo transfer concerning the woman's menstrual cycle is another critical factor. Synchronization between the embryo's developmental stage and the endometrial receptivity is vital. Personalized protocols and careful monitoring of hormonal levels contribute to better timing, enhancing the chances of successful implantation. Lastly, considering individualized patient factors, such as uterine anatomy and the woman's overall health, is essential. Tailoring the embryo transfer technique to the specific needs of each patient increases the likelihood of a positive outcome. In conclusion, continuous education, technological advancements, personalized approaches, and a patient-centered focus are key elements in improving the embryo transfer technique. Implementing these strategies can contribute to higher success rates in IVF procedures, bringing hope to individuals and couples seeking to build their families through assisted reproductive technologies.

1. Embryo Transfer
Tips & Tricks
Dr Kaberi Banerjee

2. Preparation before ET
• History of difficult
IUI/HSG/ET
• Previous Pelvic Surgeries
• Anxiety
• Non consummation

3. Preparation before ET
• P/S
• Mock ET
• GA
• Scan before ET
• Hormonal levels

5. Consents – IVF process in Covid Pandemic

6. Consent – Embryo transfer and Embryo freezing

7. Documentation

8. Discuss Embryology Details
• Delayed
• Cleavage/Blastocyst
• Cryopreservation

9. No. of embryos to transfer

10. Embryo Transfer (ET)
• Make patient comfortable-
Lithotomy
• Bladder Full (not bursting)
• Ultrasound and Light
Settings

11. Role of Full Bladder
• Straightening of cervico-
uterine axis
• Clear visualization

12. Cleaning the cervix
• Gentle speculum insertion
• Cleaning with normal saline/media
• 1 cc syringe
• Sterile cotton buds

13. Cervical Mucus
• Mucus plug in catheter tip can cause
– Blocking the passage of embryos
through the tip of the catheter
– Pulling embryos back from the site
of the expulsion
– Contaminating intrauterine
environment with cervical flora
– Retention of embryos
– Damage to the embryos
– Improper embryo placement
– Lower pregnancy rate

14. Type of catheter
• Soft catheter
• Stiff catheter

15. ET catheter
Cook Gaurdia Access Cook Sydney IVF

16. ET catheter
Wallace ET catheter Labotect ET catheter

17. ET Catheters

18. Steps in ET
• Outer insertion
• Inner Check
• Embryo Loading

19. Precautions during ET
• Follow Inner
• Distance between tip of
catheter and uterine fundus
= 1.5-2 cm(MIP)

20. Steps in ET
• Gentle but firm Push
• Flow Pattern
• Withdraw
• Examination of Catheter
and Embryos

21. Steps in ET
• Operator Performance
• Rest
• Luteal Support

22. ASRM Standard Embryo Transfer Protocol Template
ASRM
Standard Embryo Transfer Protocol
Systematic Review/Guideline Survey of SART
Medical Directors
Step 1 Prepare for ET procedure by reviewing
prior mock or transfer notes
Step 2 Prepare patient for procedure using
analgesics & other techniques
• Fair evidence - Acupuncture performed
around time of ET does not improve PR
• Insufficient evidence - To recommend
for or against analgesics, massage,
general anesthesia, TEAS whole
systems– traditional Chinese medicine
to improve PR
Routine patient
relaxant for ET
Yes 46%
No 54%
Step 3 Time out process

23. ASRM
Standard Embryo Transfer Protocol
Systematic Review/Guideline Survey of SART Medical
Directors
Step 4 Use transabdominal scan • Good evidence - based on 9 RCTs
to recommend TA ultrasound
guidance during ET to improve
CPR and LBR
• Insufficient evidence - to
recommend for or against
selective USG guidance
Use of USG guidance
Always 93%
Selectively 4%
Never 3%
Step 5 Practitioner preparation Surgical mask?
Yes 62%
No 38%
Sterile gloves?
Yes 89%
No 11%

24. ASRM
Standard Embryo Transfer Protocol
Systematic Review/Guideline Survey of SART Medical
Directors
Step 6 Placement of speculum
Cleaning/ flushing of vagina & cervix
Cleanse cervix?
Yes 96%
No 4%
With:
Saline 17%
Media 78%
Other 2%
NA 3%
Step 7 Remove mucus from ECC Fair evidence - benefit to
removing cervical mucus at the
time of ET to improve CPR and
LBR
Remove mucus?
Yes 75%
No 25%
How?
Cotton swab 26%
Flush 20%
Both 31%
Aspirate 6%

25. ASRM
Standard Embryo Transfer Protocol
Systematic
Review/Guideline
Survey of SART Medical
Directors
Step 8 Prepare ET catheter and traverse cervix by
below techniques –
• Direct transfer
• Trial followed by transfer
• Afterload transfer
• Trial transfer converted into an afterload
transfer
Good evidence - to
recommend the use of a soft
embryo transfer catheter to
improve IVF ET pregnancy
rate
Predominant technique used:
Trial followed by transfer 40%
(includes trial converted to
afterload)
Afterload 31%
Step 9 Place catheter tip at ideal location Fair evidence - placement of
catheter tip in upper or
middle (central) area of
uterine cavity, greater than 1
cm from fundus for embryo
expulsion, optimizes PR
Location of catheter tip:
Upper third 66%
Middle third 29%
Lower third 5%
Closest distance to fundus:
0.5 cm - 7%
1 cm - 47%
1.5 cm - 39%
2 cm - 7%

26. ASRM
Standard Embryo Transfer Protocol
Systematic Review/Guideline Survey of SART Medical Directors
Step 10 Expel embryos and withdraw catheter
immediately
Fair evidence - to recommend
immediate withdrawal of
embryo transfer catheter after
embryo expulsion
After embryo expulsion catheter
removed:
Immediately 31%
5 – 10 seconds 33%
30 seconds 22%
1 minute 12%
Other 2%
Step 11 Check catheter for retained embryo(s)
If present – reload new catheter and
immediately re-transfer embryo(s)
Fair evidence - Retained
embryos in transfer catheter
and immediate re- transfer do
not affect implantation, CPR or
spontaneous abortion rates
Retained embryos re transferred in:
Same catheter 33%
New catheter 67%
Step 12 Patient gets up from transfer table
(without rest)
Good evidence – not to
recommend bed rest after ET
Patient ambulates after transfer:
Immediately 32%
5 – 10 min 13%
10 – 15 min 13%
15 – 30 min 27%
30 min 14%
>1 hour 2%

27. Difficult ET
• Obesity
• Retroverted
• Cervical Stenosis
• Cervix pulled up
• Poor visualization

28. Cervical Canal Findings in Difficult Embryo Transfer
• False passage in the cervix with acute angulation
• Tortuous cervical canal with a fibrotic internal os
• Severely fibrotic internal os
• Fibroid close to cervical canal

29. Hysteroscopic Procedures
– Cervical canal shaving
– Refashioning of cervical canal
with Versapoint
– Hysteroscopic evaluation and
placement of a Malecot
catheter
– Hysteroscopic myosure
morcellation

30. Difficult Embryo Transfer
– If anticipated may plan under GA
– Require a firmer catheter
– Stylet
– Tenaculum
– Sounding
– Cervical Dilatation

34. Difficult ET

35. Transvaginal Ultrasound Guided ET

37. Affects Does Not Affect
Remove Cervical Mucus Acupuncture
Tip placement in mid cavity >1cm from
fundus
Routine Antibiotics
Immediate Withdrawal of Catheter Powdered Gloves
Mucus on Catheter
Immediate Retransfer of retained
embryos

38. Analgesics
Massage
Chinese Medicine
Blood on catheter
Injection speed

39. If no previous H/o difficult ET
P/S
Require partial full bladder
Afterload technique
Use of Stylet
Labotect Catheter
If previous H/o difficult ET
P/S examination & Mock ET
Hysteroscopy
ET under GA
Labotect Catheter
Hysteroscopic resection
AFGC Protocol
Difficult ET Cases

40. Under Vision ,Gentle, Fast ,

41. Thank You!