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4.  Embryo Transfer Technique

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a. Day three embryo transfer

Many programs transfer embryos on the 3rd day after fertilization. Our IVF program has been very happy with our pregnancy rates with day 3 transfers and we have been reluctant to change, even though we did the 1st blastocyst transfer 10 years ago. Additionally, in some patients we can do assisted hatching on day 3 embryos which helps with implantation in certain situations. On day 3, the embryos typically look like the photo below in Figure 9.

Figure 9. Day 3 embryo with 7 cells and some fragmentation.

b. Blastocyst transfer

Blastocyst transfer involves culturing the embryos 2-3 additional days in specialized media. On day 4 we see the morula stage embryo which has a mass of confluent cells as shown in Figure 10.

Figure 10. Morula stage embryo.

On day 5, the blastocyst stage embryo is characterized be the inner cell
mass, the future embryo, the blastocoel cavity and the trophoectoderm
which will become the future placenta. This is shown in figure 11.

Figure 11. Blastocyst stage embryo

It is the blastocyst stage embryo that will hatch from the zona pellucida and
implant. Thus, it is intuitive to assume that this would be the best stage to
transfer the embryos. Culture media had to be developed that
addresses the unique nutritional requirements of this stage. Theoretically, implantation rates would be higher and pregnancy rates should be higher. Additionally, fewer embryos should have to be transferred. It has been a decade since the 1st blastocyst transfers were performed and our practice was the 1st to do routine transfers in 1998 in Indiana. We noted, however,after initial successes that the long term pregnancy rates did not appear to higher. Some patients had embryos that failed to develop and arrested. The question is of course if the culture media or an intrinsic embryo defect is responsible for the arrest. It is difficult to determine. Were the embryos well developed on day 3? The incidence to monozygotic and dizygotic twinning is higher and these may have increased prenatal complications.The number of embryos available to cryopreservation is lower, potentially limiting this very cost effective potential therapy. While the pregnancy rate in good prognosis patients (i.e. young, high number eggs/embryos) is probably higher than day 3, the rates with day 3 are still high nonetheless. Overall, when the majority of studies are reviewed, the pregnancy rates with blastocyst transfer is not higher than day 3 transfers.

c. Trial transfer

We feel the trial transfer is an important part of the IVF procedure. The embryo transfer is the technically crucial. It is possible that a poor transfer would result in lower pregnancy rates. It is our practice to do a trail transfer the month before the stimulation procedure. Also, a trial pass of the catheter is done right before the embryos are transferred to confirm the easy of transfer. The trial transfer involves doing a speculum exam, placing a transfer catheter with a syringe attached with saline through the cervix, and removing the speculum with the catheter still in the uterus. We then perform trans-vaginal ultrasonography. We are able to see the catheter in the cervix. We can tell if the uterus is tilted (i.e. retroflexed or anteflexed). If so, the following month when we do the actual transfer, we can use a stylette to negotiate curvature of the cervix. We have seen patients where the cervix makes a literal U-Turn. It is best to know this ahead of time rather than when we have embryos ready for transfer. We then inject some of the saline through the syringe (i.e. saline infusion sonogram, hydrosonogram). The saline will fill the uterine cavity. We see uterine polyps, small sub-mucosal myomas and scar tissue that might have been missed with a regular ultrasound (Figure 12). These may lower the implantation rate and can be corrected before we do the actual IVF procedure.

Figure 12. Uterine polyp shown with saline infusion

Some patients that have had prior Caesarian Sections may have a defect at the site of the uterine incision as shown in Figure 13. The saline in the cavity spills down towards the cervix and fills this potential space. This may have been missed with a prior hysterosalpingogram because the balloon at the tip of the catheter is placed above the cervix in the lower uterine cavity so it is above the C-Section scar. The importance of this may have to do with the embryo transfer. The actual embryo transfer catheter (i.e. Wallace Catheter) is remarkably flimsy and soft when loaded with embryos and at body temperature. If the tip were to be twisted or turned around in the C-Section scar and visualization with the ultrasound was difficult it is possible that the embryos may not be place appropriately in the cavity. When we have this defect, we use the stylette and under ultrasound guidance place the outer catheter sheath beyond the defect. Our goal is to have as easy of embryo transfer as possible.

Figure 13. Trail transfer/ SIS showing defect in prior Caesarian Section scar

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