Transcript Repeated ET failures

Tehnika embrio transfera i
uspjeh IVF-a
Renato Bauman
KB Sveti Duh
Klinika za ginekologiju i porodništvo
Zagreb, Croatia
VIII Hrvatski kongres o humanoj reprodukciji, Brijuni
10.09.2011.
Embrio transfer – “evidence based”
pristup
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85% prenešenih
zametaka se ne
implantira
Točan uzrok ostaje
nepoznat !!
Mogući uzroci
neimplantacije:
1.
2.
3.
Edwards RG 1995 Hum reprod
Tehnika ET
Receptivnost
endometrija
Sposobnost zametka za
implantaciju
Embrio transfer – EB - Tehnika ET
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Prema randomiziranim studijama i metaanalizama samo tri postupka mogu
utjecati na poboljšavanje stope
implantacije
Embrio transfer – EB - Tehnika ET
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ET pod UZV kontrolom
Sallam HN, Fertil Steril 2003 DA
Abou-Setta AM, Fertil Steril 2007 DA
Brown J, Cochrane Database 2010 DA
Drakeley AJ, Hum Reprod 2008 NE!!!
Pun mjehur !!??
Embrio transfer – EB - Tehnika ET
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Prijenos zametaka 15-20 mm ispod
fundusa
Coroleu B, Barri PN, Carreras O et al: The influence
of the depth of embryo replacement into the uterine
cavity on implantation rates after IVF: a controlled,
ultrasound guided study. Hum Reprod 2002.
Sredina uterusa, ili bliže istmusu!
ET
Embrio transfer – EB - Tehnika ET
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Probni (“DUMMY”) ET prije “stvarnog”
Mansour R, Aboulghar M, Serour G.
Dummy embryo transfer: a technique that minimizes
the problems of embryo transfer and improves the
pregnancy rate in human in vitro fertilization
Fertil Steril 1990.
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Izbor katetera ?
Coroleu B, Hum Reprod 2006
Abou-Setta AM, Hum Reprod 2005 SOFT!
Embrio transfer – EB - Tehnika ET
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Randomizirane studije ukazuju da slijedeći
postupci NEMAJU utjecaja na implantaciju
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ispiranje cervikalnog kanala s medijem
Sallam HN et al The importance of flushing the
cervical canal with culture medium prior to embryo
transfer. Fertil Steril 2000
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Ostavljanje katetera intrauterino kroz 30
sekundi
Martinez F et al. Ultrasound-guided embryo transfer:
Immediate withdrawal of the catheter versus a
30-seconds wait. Hum Reprod 2001
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Mirovanje u krevetu poslije ET
Botta G, Grudzinskas G. Is a prolonged
bed rest following embryo transfer useful?
Hum Reprod 1997
Purcell KJ et al. Bed rest after ET:a
randomized control trial. Fertil Steril 2007
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Antibiotici poslije ET
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Učinak držanja cerviksa hvataljkom
Egbase PE et al. Prophylactic antibiotics and
Endocervical microbial inoculation of the
endometrium at ET. Lancet, 1999.
Brook N et al. A randomized control trial of
prophylactic antibiotics prior to ET. Hum Reprod
2006
ET !
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Krv u kateteru i boravak zametaka duže
od 120 sekundi u kateteru značajno
smanjuje stopu implantacije!
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Zrak u kateteru, dva transfera u istom
ciklusu, mirovanje, spolni odnos nakon
prijenosa zametaka ni korištenje
sildenafila ne utječu na rezultat prijenosa
zametaka
Sallam HN Curr Opin Obstet Gynecol 2005
Alvero R, Hum Reprod 2003
Kvaliteta zametaka
Receptivnost endometrija
Ocjena receptivnosti endometrija
- debljina endometrija (volumen 3D)
- ehogenost endometrija
- prokrvljenost endometrija (CD)
Uterine Profile
Endometrial thickness
Endometrial morphology
Myometrial echogenicity
Uterine artery pulsatility index
Protodiastolic notch
End-diastolic flow blood
Spiral artery blood flow (color
or power Doppler)
Total
Score
<7 mm
7 mm
Triple line
Others
Homogeneous
Nonhomogeneous
3
>3
Present
Absent
Present
Absent
Present
Absent
0
3
3
0
1
0
4
0
0
2
4
0
3
0
20
Prije IVF-a (ET) provjeriti UTERUS
s TVCD (bolje s 3D)
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Polipi
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Anomalije
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Submukozni miomi
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Intrauterine priraslice
UTERUS SUBSEPTUS
Jajovodi!
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Saktosalpinks –
neprijatelj implantacije
– prethodno
salpingektomija ili
koagulacija istmičnog
dijela tube
Tanki endometrij
< 8 mm
 Odgoditi transfer do 5 dana ili
kripohraniti zametke i prijenos u
slijedećem prirodnom ciklusu
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Lijekovi
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NSA
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Diazepam?
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PROGESTERON vaginalno, HCG, aGnRH
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E2 (2x1 mg)? Do 8 mg/dan???
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ASPIRIN 1 mg/kg?
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NMH (doza?, trajanje?)
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Kortikosteroid (doza?, trajanje?)
ALTERNATIVE ?
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GINKO
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AKUPUNKTURA
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HISTEROSKOPIJA
Optimizing the technique of embryo
transfer Lindsay Mains Fertil Steril 2010
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Summary
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Evidence-based Guidelines
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1. Effort should be made to avoid “difficult” transfers.
2. Ultrasound guidance will result in easier transfers with improved outcomes.
3. Soft catheters should be used when feasible.
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Recommendations Based on Expert Opinion
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1. Trial transfers allow better preparation for difficult transfers.
2. Cervical mucus should be removed to potentially decrease bacterial
contamination and mucus plugging of the catheter.
3. Embryos should be deposited in the midportion of the uterus.
4. Negative pressure should be minimized during withdrawal of the catheter.
5. The procedure should be done in a minimum amount of time.
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