Tehnika embrio transfera i

uspjeh IVF-a
Renato Bauman
KB Sveti Duh
Klinika za ginekologiju i porodnitvo
Zagreb, Croatia
VIII Hrvatski kongres o humanoj reprodukciji, Brijuni
10.09.2011.

Embrio transfer evidence based

pristup

85% preneenih
zametaka se ne
implantira
Toan uzrok ostaje
nepoznat !!

Mogui uzroci
neimplantacije:
1.
2.
3.

Edwards RG 1995 Hum reprod

Tehnika ET
Receptivnost
endometrija
Sposobnost zametka za
implantaciju

Embrio transfer EB - Tehnika ET

Prema randomiziranim studijama i metaanalizama samo tri postupka mogu

utjecati na poboljavanje stope
implantacije

Embrio transfer EB - Tehnika ET

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

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 blie istmusu!

ET

Embrio transfer EB - Tehnika ET

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.

 Izbor

katetera ?

Coroleu B, Hum Reprod 2006

Abou-Setta AM, Hum Reprod 2005 SOFT!

Embrio transfer EB - Tehnika ET

Randomizirane

studije ukazuju da slijedei

postupci NEMAJU utjecaja na implantaciju

 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

 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

 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

 Antibiotici
Uinak

poslije ET

dranja 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 !
Krv

u kateteru i boravak zametaka due

od 120 sekundi u kateteru znaajno
smanjuje stopu implantacije!

Zrak

u kateteru, dva transfera u istom

ciklusu, mirovanje, spolni odnos nakon
prijenosa zametaka ni koritenje
sildenafila ne utjeu na rezultat prijenosa
zametaka
Sallam HN Curr Opin Obstet Gynecol 2005
Alvero R, Hum Reprod 2003

Kvaliteta zametaka

Receptivnost endometrija

Ocjena receptivnosti
endometrija

Prije IVF-a (ET) provjeriti UTERUS

s TVCD (bolje s 3D)
Polipi
Anomalije
Submukozni
Intrauterine

miomi

priraslice

UTERUS SUBSEPTUS

Jajovodi!
Saktosalpinks

neprijatelj implantacije
prethodno
salpingektomija ili
koagulacija istminog
dijela tube

Tanki endometrij
<

8 mm
Odgoditi transfer do 5 dana ili
kripohraniti zametke i prijenos u
slijedeem prirodnom ciklusu

Lijekovi

NSA

Diazepam?

PROGESTERON vaginalno, HCG, aGnRH

E2 (2x1 mg)? Do 8 mg/dan???

ASPIRIN 1 mg/kg?

NMH (doza?, trajanje?)

Kortikosteroid (doza?, trajanje?)

ALTERNATIVE ?

GINKO
AKUPUNKTURA
HISTEROSKOPIJA

Optimizing the technique of embryo

transfer Lindsay Mains Fertil Steril 2010

Summary

Evidence-based Guidelines

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.

Recommendations Based on Expert Opinion

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.