Good luck!

In my opinion there is no need for extended bed-rest post-transfer.

Unquestionably, the IVF doctor’s expertise in performing embryo transfer ranks as one of the most important factors that will determine IVF outcome. It takes confidence, dexterity, skill, gentility and above all, experience to do a good transfer. This having been said, of all the procedures in IVF this is the most difficult to teach. It is a true “art” and there is little doubt that many women will fail to conceive following IVF simply because their doctor could not perform this procedure optimally.

Good quality embryos are those whose cells (blastomeres) continue to divide at a regular and predictable rate, such that  within 72 hours of fertilization they contain 6-9 cells and within 5-6 days, they will have developed into  expanded blastocysts.. Such embryos are the ones that are most likely to be “competent” (i.e., able to propagate a pregnancy upon being transferred to a receptive uterus). Those that do not, are the ones least likely to be “incompetent”. In fact embryos that fail to develop into expanded blastocysts within 5-6 days of being fertilized, are almost invariably, chromosomally abnormal (aneuploid) and are unworthy of transfer .

The addition of genetic embryo testing by methods such as next generation gene sequencing -NGS (which assesses all its chromosomes), at least doubles the ability to select truly “competent” embryos for transfer. This significantly increases the baby rate per embryo transferred, markedly reduces the likelihood of miscarriage, and minimizing the occurrence of chromosomal birth defects such as Down’s syndrome. Shortly before being transferred, the embryos are put together in a single laboratory dish containing growth medium. The laboratory staff informs the clinic coordinator that the embryos are ready for transfer, and the coordinator prepares the patient and informs the physician that a transfer is imminent.

Ultrasound Guided Embryo Transfer… A Must!

Today all embryo transfers should in my opinion be performed under direct ultrasound guidance to ensure proper placement in the uterine cavity. All other factors being equal , such practice, properly conducted, will significantly enhanced embryo implantation and pregnancy rates.

The full bladder:

We prefer to perform all embryo transfers when the woman has a full bladder. This facilitates the visualization of the uterus by abdominal ultrasound and causes reflex nervous suppression of uterine contractility. . The patient is allowed to empty her bladder 10 minutes following the embryo transfer.

Relaxation:

It is important that the woman be as relaxed as possible during the embryo transfer because many of the hormones that are released during times of stress, such as adrenalin, can cause the uterus to contract. Accordingly we offer our patients, an oral tranquilizer (usually 5mg of oral diazepam or Valium) about a half hour prior to the embryo transfer, to relax the woman and reduce apprehension. Some IVF programs believe that imagery helps the woman relax and feel positive about the process and in the process reduce the stress level. In such a program a counselor and/or clinical coordinator may help the woman focus on visual imagery for a few minutes immediately prior to embryo transfer so as to enhance her relaxation.

How Many Embryos are Transferred?
There is an overriding need to minimize the occurrence of multiple gestations, especially high order multiples (triplets or greater). This is because of the risk of prematurity-related complications increase proportionate to the number of babies in the uterus. As a rule of thumb however, I transfer only one (1) or two (2) blastocysts at a time.

There are several confounding considerations in determining how many embryos to transfer at a time:

1. The older the woman who produces the eggs, the greater the likelihood that upon being fertilized, the resulting embryo(s) would be “incompetent:” As an example; in the case of a woman of 33 years each morphologically good looking embryo (those with a “ high grade”) would have about a 20-30% chance of propagating a normal pregnancy while for a woman in her mid-forties, the comparable rate would be no greater than 5-10%.
2. Another issue relates to the perceived “microscopic quality” of the embryo(s) being transferred. When a decision on how many embryos to transfer is based upon the microscopic appearance of such embryos than their microscopic “grade” should be taken into consideration.
3. The stage of development that the embryos have reached by the time of the ET must also be taken into account in deciding how many to transfer. The reason for this is that expanded , day 5-6) blastocysts are far more likely to propagate pregnancies than are cleaved (day 2-3) embryos. Accordingly, fewer blastocysts need be transferred at a time.
4. Genetic competency of the embryos: Since an embryo’s “competence” is far more likely in cases where it tests NGS- normal (all its chromosomes are present and intact). In such cases the transfer of only one such embryo is likely to produce a baby about 50% of the time, (regardless of the age of the egg-provider). It is thus is completely feasible to restrict the number of such embryos that are transferred to one and sometimes two.

The ET Process:

In those programs that rely relaxation therapy, as soon as the woman is sufficiently relaxed a counselor or nurse will initiate the coaching exercises during the procedure. In some cases, a specialist will administer acupuncture.   When the woman is in the proper position, and her bladder is adequately filled, the physician first inserts a speculum into the vagina to expose the cervix and then may clean the cervix with a sterile salt solution to remove any mucus or other secretions.  An abdominal ultrasound transducer is placed suprapubically on the lower abdomen to allow clear visualization of the uterus is clearly visualized. The physician then informs the embryology laboratory and awaits the arrival of the transfer catheter loaded with the embryo(s). Upon delivery of the loaded catheter to the physician performing the ET, he/she gently guides the catheter through the woman’s cervix into the uterine cavity. Once ultrasound examination confirms that the catheter is in place, the embryologist carefully injects the embryos into the uterus, and the physician slowly withdraws the catheter. The catheter is immediately returned to the laboratory where it is examined under the microscope to make sure that all the embryos have been released. Any residual embryos would be re-incubated, and the transfer process would be repeated to deliver the remaining embryos.

ET  performed under anesthesia/conscious sedation:

In cases where ET requires a lot of manipulation or when the woman is emotionally incapable of dealing with the process, I would opt for her being put under conscious sedation (using Fentanyl or Propafol) and then performing the same procedure as described above. This approach does not in any way compromise success

Transmyometrial ET:

 In cases where for anatomical reasons, it is impossible to traverse the cervical canal, the patient can undergo a transmyometrial ET. Here, with the woman under anesthesia/conscious sedation, a special (Kato Asch) needle  is passed through the uterine wall (myometrium) into the uterine cavity. Under transabdominal ultrasound guidance, a  thin catheter containing the embryo(s) is threaded through the lumen of the catheter into the uterine cavity and the embryo’s are discharged.. Performing transmyometrial ET is takers quite a bit of skill to perform. It is in my opinion, a “last resort approach” but when required it can be very effective an successful. I have conducted at least 2 dozen such procedures over the years and have had considerable success.

Post-Embryo transfer instructions:

I usually require that my patients remain recumbent for about 30mn after the ET. Thereupon they return to their home/hotel. I do not require absolute bedrest. However, I suggest that they limit their physical activities for about 12 hours and try to avoid undue stress. I also advise them to restrict caffeine and alcohol intake and to avoid sexual penetration until ultrasound confirmation of pregnancy at 6-7 weeks or until pregnancy is discounted.

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ADDENDUM: PLEASE READ!!

INTRODUCING SHER FERTILITY SOLUTIONS (SFS)

Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.

If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or,  enroll online on then home-page of my website (www.SherIVF.com). 

PLEASE SPREAD THE WORD ABOUT SFS!

Geoff Sher

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1.From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) “

http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

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