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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 419-426

Comparison between transvaginal and transabdominal ultrasound-guided embryo transfer: a randomized, prospective trial


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission30-Jan-2019
Date of Decision07-Mar-2019
Date of Acceptance10-Mar-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Shreef S Menshawi
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shebeen El-Kom
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_24_19

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  Abstract 


Objective
The aim of this study was to compare between transvaginal ultrasound (TVS) and transabdominal ultrasound (TAS)-guided embryo transfer (ET) as regards clinical pregnancy rate, patient discomfort, time required for ET, and endometrial visualization during ET.
Background
ET is an operator, and equipment-dependent procedure. Ultrasound-guided ET allows placing embryos at the desired level within the endometrial cavity.
Patients and methods
This randomized, prospective trial included 178 infertile couples from Al Shatbi Reproductive Gynecology Unit in Alexandria University Hospital, during the period between June 2016 and May 2018. The patients were divided randomly prior to ET into two equal groups: the first group used TAS guidance for ET and the second group used the TVS guidance for ET.
Results
The clinical pregnancy rate showed no statistical differences in both groups: 39/89 (43.8%) versus 42/89 (47.2%) (P = 0.652). The mean discomfort intensity during ET was significantly higher in TAS-guided ET group (1.81 ± 1.03 vs. 1.50 ± 0.92) (P = 0.040). The ET took longer time in the transvaginal group. Median 66.0 versus 60.0 s in the transabdominal group (P = 0.125). The optimal endometrial visualization during ET was statistically higher in the transvaginal group: 25 (28.1%) and 45 (50.6%) (P = 0.002).
Conclusion
There was no significant difference between TVS-guided ET and TAS-guided ET as regards the clinical pregnancy rate. Although the TVS-guided ET took longer time, it allowed less patient discomfort and better endometrial visualization during ET.

Keywords: embryo transfer, transabdominal, transvaginal, ultrasound


How to cite this article:
Samy AA, El-Kassar YS, Gaafar SS, Hamza HA, Menshawi SS. Comparison between transvaginal and transabdominal ultrasound-guided embryo transfer: a randomized, prospective trial. Menoufia Med J 2020;33:419-26

How to cite this URL:
Samy AA, El-Kassar YS, Gaafar SS, Hamza HA, Menshawi SS. Comparison between transvaginal and transabdominal ultrasound-guided embryo transfer: a randomized, prospective trial. Menoufia Med J [serial online] 2020 [cited 2020 Oct 22];33:419-26. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/419/287763




  Introduction Top


In-vitro fertilization (IVF) success rates increase slowly, with an overall delivery rate estimated at about 20%[1]. Suboptimal results in IVF are mainly due to embryo aneuploidy, especially in women of late reproductive age[2], defects in endometrial receptivity[3], and possibly due to imperfect embryo transfer (ET) techniques[4]. It has been estimated that poor ET technique may account for up to 30% of all failures in assisted reproduction[5]. Some variables may affect ET technique such as the avoidance of blood during the procedure[6], the type of catheter used[7], the timing of catheter removal[8], and the period of patient rest[9]. The utility of ultrasound nowadays during ET has some advantages related to the low cost of the technology, the possibility of placing embryos at the desired level within the endometrial cavity, and the possibility for patients to watch the whole procedure[10]. The disadvantages of ultrasound guidance during ET may include the need for a second operator, a longer procedure time, and the inconvenience of filling the patient bladder[11]. The recommendation for use of ultrasound is still under debate despite a large number of randomized, controlled trials[12],[13]. Transvaginal ultrasound (TVS) guidance was first described in the 1990's by Hurly et al., who showed the role of TVS in improving the ET technique over the clinical touch method[14]. In this study, we compared between TVS and transabdominal ultrasound (TAS)-guided ET as regards clinical pregnancy rate, patient comfort, time required for ET, and the degree of endometrial visualization during ET.


  Patients and Methods Top


This was a prospective, randomized, comparative clinical study done during the period between June 2016 and May 2018, at the Reproductive Gynecology Unit, Al Shatbi University Hospital, Alexandria Governorate, Egypt.

Calculation of the sample size

The sample size was calculated using computer sample block randomization type. During the preselection visit, exclusion and inclusion criteria were applied. Two hundred and twenty patients were enrolled into the study according to consort guidelines. About 32 patients refuse to participate, three case were excluded because of cervical stenosis at mock ET. Another seven patients were excluded because the intracytoplasmic sperm injection (ICSI) cycle was stopped before reaching ET [no adequate response to controlled ovarian superovulation (COS), no fertilized oocytes, and no available embryos]. Overall, 178 patients were enrolled into the study and randomized on the day of ET with a 1: 1 ratio into two groups: 89 patients were scheduled to undergo TAS-guided ET, whereas 89 patients were scheduled to receive TVS-guided ET. The sample size was based on the past review of the literature, Porat et al.[15], on 178 patients, 89 for every single group, are required to have a 90% chance of detecting, a decrease in the primary outcome measure in clinical pregnancy rates.

The patients were randomized into two groups prior to the first ET: group A (89 patients): embryos were transferred under TAS guidance. Group B (89 patients): embryos were transferred under TVS guidance.

Inclusion criteria

All patients undergoing autologous ICSI and frozen ET cycles were included in the study. Written consent was obtained from each subject candidate.

Exclusion criteria

Included severe ovarian hyperstimulation, poor responders (antimullerian hormone <0.5), patients with cervical stenosis. and uncorrected structural mullerian anomalies.

Patient evaluation

Demographic data included patient age, BMI, duration of infertility, main indications for ICSI, combined, tubal, male, unexplained, ovarian.

Basal hormonal prolife: serum estradiol, follicle-stimulating hormone, thyroid-stimulating hormone, and antimullerian hormone in certain cases.

Basal TVS (uterine position, antral follicular count, cervical length, uterine length, and uterocervical angle): The uterocervical angle was measured by both TVS and TAS: (a) no angle, (b) small angle (<30°), (c) moderate angle (30°–60°), (d) large angle (>60°) (used with permission from Cozzolino et al.[16]) [Figure 1].
Figure 1: Measuring the uterocervical angle by transabdominal ultrasonography: (a) no angle, (b) small angle (<30°), (c) moderate angle (30°–60°), (d) large angle (>60°) (used with permission from Sallam[13]).

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One month prior to enrollment in the study, a written informed consent was given to each patient to review as well as the opportunity to ask questions.

Uterine cavity and mock ET: All patients underwent a 3D TVS within 3 months prior to ET. All patients underwent ultrasound-guided mock ET using both the TAS-guided approach (with full bladder) and TVS transvaginal one (after bladder emptying). If a difficult mock ET is encountered (defined as requiring at least two attempts; presence of blood on the catheter, resistance to advancement of ET catheter needing cervical traction and/or >5 min), and correction with either cervical dilation or operative hysteroscopy was performed within 1–2 months of their ICSI cycle.

Controlled ovarian hyper stimulation protocol: for gonadotropin-releasing hormone (GnRH), antagonist cycle ovarian stimulation was initiated on day 3 of the cycle with 150–450 mIU/ml/day of urinary gonadotropins (Menogon ampoule 75 mIU/ml) for the first 4 days of treatment; dosing is adjusted according to ovarian response. Daily injection of GnRH antagonist (Cetrotide ampoule 0.25 mg, subcutaneous, Merck international inc., 28820 Single Oak Drive, Temecula, California 92590, United States of America) was begun when the leading follicles were 12–14 ml.

For GnRH, agonist cycles, after confirmation of ovarian suppression (serum E2 <50 pg/ml) for long luteal suppression (10–14 days) and for 'flare' cycles, on day 3 of the cycle following a withdrawal bleeding, microdose GnRH-agonist (decapeptyl 0.1 mIU/ml) has begun, followed by urinary gonadotropins (Menogon ampoule 75 mIU/ml) (150–450 mIU/ml/day) and was adjusted according to ovarian response.

Monitoring during ICSI cycles: all cycles were monitored by TVS (Madison Logic a, 6.5 MHz, Madison Logic Corporate Headquarters, 257 Park Avenue South, 5th Floor, New York, New York 10010) and by serum estradiol levels starting on day 5 of the stimulation and was adjusted according to response. And the endometrium was evaluated as regards endometrial thickness (mm) and endometrial pattern. When the follicles reached 18–20 mm, 5000–10 000 IU human chorionic gonadotropin (choriomon ampoule 5000 IU/ml) was given followed by transvaginal oocyte aspiration 36 h later.

Frozen ET protocol: included elective verification of embryos due to fear of ovarian hyperstimulation or high-serum progesterone of more than 1.5 ng/ml. The regimen used: GnRH-agonist suppression and then oral micronized estradiol and progesterone supplementation.

In-vitro insemination and intracytoplasmic sperm injection

Laboratory data: include the number of retrieved oocytes, mature metaphase ii oocytes, and available embryos, embryo grade score, day ET, and finally the number of transferred embryos. During the period of research, there was no change in the oocyte retrieval, culture media, and culture systems. After making the decision to participate in the research by patients, the research coordinator reviewed and obtained their consent. On the day of the ET, all patients were asked to arrive with full bladder. The patients were assigned to either a TAS or TVS guided approach according to a computer-based randomization. For ET, the Labotect Embryo Transfer catheter (no. 13366; 200212, 37087 Göttingen, Germany) was used.

ET: A transcervical ET was performed 3–5 days after oocyte retrieval.

TVS guided ET: A vaginal speculum was introduced after bladder emptying. After that the ultrasound probe with a sterile condom was inserted through the speculum to assess the uterine contour and degree of angulation and the ease of uterine visualization. Embryos were then loaded into an ET catheter and then the outer catheter placed in the lower uterine segment. The ultrasound probe was reintroduced through the speculum alongside the transfer catheter and then the inner catheter was advanced under ultrasound guidance to within 1.0–1.5 cm from the upper fundus. Finally, the catheter was inspected for any retained embryos and the vaginal probe was reintroduced through the speculum to identify the position of the air-bubble–fluid interface.

TAS-guided ET: For those who underwent the TAS guided ET, adequate bladder filling was required prior to ET to delineate the pelvic anatomy and then a speculum was introduced and similarly, the transfer catheter was shaped to the degree of angulation. The catheter was then loaded and under ultrasound guidance performed by the IVF nurse, the tip of the catheter was advanced to within 1.5–1.0 cm from the upper fundus and the embryos are injected and identified as the air-bubble–fluid interface. Finally, the catheter was inspected for any retained embryos and the patients were allowed to empty their bladder. Following the ET, bed rest was recommended for 30 min. serum B human chorionic gondotrophin (B-hCG) levels were done 15 days following ET. Two weeks after that clinical pregnancies were confirmed by the presence of gestational sac.

Measured outcomes: primary outcomes were clinical pregnancy. Secondary outcomes were the time required for ET defined as the time from when the catheter is handed to the transferring physician to the time it was returned to the transferring embryologist, degree of cramping, and pain by visual analog scale and endometrial visualization at the time of ET.

Statistical analysis: data were fed to the computer and analyzed using IBM SPSS software package version 20.0. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). The Kolmogorov–Smirnov and Shapiro and D'agostino tests were used to verify the normality of distribution of variables. Comparisons between groups for categorical variables were assessed using χ2-test (Fisher's or Monte Carlo). Student's t-test was used to compare two groups for normally distributed quantitative variables while Mann–Whitney test was used to compare between two groups for abnormally distributed quantitative variables. Significance of the obtained results was judged at the 5% level.


  Results Top


The flow diagram of the study according to the consort guidelines is shown in [Figure 2]. A total of 220 women undergoing ICSI between September 2016 and May 2018 at the Reproductive Gynecology Unit at Al Shatbi University Hospital Alexandria, Egypt. About 32 patients refuse to participate and three cases were excluded because of cervical stenosis at mock ET. Another seven patients were excluded because the ICSI cycle was stopped before reaching ET (with no adequate response to COS ovulation, no fertilized oocytes, and no available embryos). Overall, 178 patients were enrolled into the study and randomized on the day of ET with a 1: 1 ratio into two groups: 89 patients were scheduled to undergo TAS-guided ET, whereas 89 patients were scheduled to receive TVS-guided ET. The baseline clinical, hormonal, and ultrasound characteristics of the patients included in the final analysis are presented in [Table 1]; the two groups of patients did not differ significantly in prerandomization cycle characteristic of the study groups (COS protocol, exogenous gonadotropin total dose, number of retrieved oocytes, number of mature metaphase II oocytes, number of available embryos, number of good quality embryos, and endometrial thickness [Table 2]. The mean number of transferred embryos, grade of transferred embryos, and the day of ET were similar in the two groups [Table 3]. The clinical pregnancy 39/89 (43.8%) versus 42/89 (47.2%) with a P value of 0.652 in the general population and showed no statistically significant differences. Subgroup analysis of the clinical pregnancy in specific groups showed clinical pregnancy in obese women, 12/31 (38.7%) versus 15/35 (42.9%). Women with retroverted uterus were 7/18 (38.9%) versus 9/20 (45.0%) with a P value of 0.703. Clinical pregnancy in women with difficult mock transfer was 4/12 (33.3%) versus. 5/10 (50.0%) but not statistically significant with a P value of 0.666. The mean discomfort intensity during ET was significantly higher in TAS-guided ET group 1.81 ± 1.03 versus 1.50 ± 0.92 with a P value of 0.023. The ET took longer time in the transvaginal group. Median 66.0 s versus 60.0 s in the transabdominal group with a P value of 0.005. Also, subgroup analysis of the optimal endometrial visualization during ET in specific groups s in obese women (35.5%) versus 18/35 (51.4%) was with a P value of 0.325. In women with retroverted uterus 3/18 (16.7%) versus 10/20 (50.0%) with a P value of 0.025 and in women with difficult mock transfer 3/12 (25.0%) versus 7/10 (70.0%) with a P value of 0.088 which was statistically significant in retroverted uterus [Table 4].
Figure 2: Follow diagram of enrollment into the study according to consort guidelines: ET, embryo transfer; TA-UGET, transabdominal ultrasound guided embryo transfer; TV-UGET, transvaginal ultrasound-guided embryo transfer.

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Table 1: Comparison between the two studied groups according to the baseline clinical, hormonal, and ultrasound characteristics of the patients

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Table 2: Comparison between the two studied groups according to prerandomization cycle characteristic of the study groups

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Table 3: Comparison between the two studied groups regarding postrandomization cycle characteristic parameters

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Table 4: Comparison between the two studied groups according to the outcome

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  Discussion Top


This study showed an equal efficacy in clinical pregnancy. Our study like Porat et al.[15] was affected by the small number of patients (186 in the interim analysis). The study by Bodri et al.[17] may be criticized for the use of different catheters in the two groups and the performance of the transfer by several operators, whereas the transfer technique requires training[18]. Finally, Karavani et al.[10]. carried out a power analysis that aimed only at investigating the reduction of patient discomfort in the Trans vaginal ultrasounds (TVUS) group. A recently published large, retrospective study by Larue et al.[19] described opposite results with an advantage for the TVUS technique. This may be related to a more precise embryo deposition in the uterine cavity, with minimal mucosal trauma[19]. Most of the randomized, controlled trials showed a low risk of bias concerning random sequence generation. In contrast, the risk of bias was considered unclear or high. Regarding patient discomfort and uterine visualization our study was in line with these results that have recently been confirmed and expanded by Karavani et al.[10] who reported that TVUS was significantly associated with a better visualization of the uterus and ET location (9.57 vs. 8.42 and 9.58 vs. 8.82, respectively) and significant reduction in pain, discomfort, and anxiety especially during procedure preparation and performance. However, Porat et al.[15] found no differences between groups concerning the degree of uterine cramping (1.2 ± 0.5 vs. 1.2 ± 0.4) and pain (1.4 ± 0.7 vs. 1.3 ± 0.5). Bodri et al.[17] found that the uterine cramping rate was comparable between the groups (27.2 vs. 18.3%) and reported 41% of light, 16% of moderate, and 6% of severe discomfort related to bladder distension in the Transabdominal ultrasound (TA-US) group. TVUS due to its higher resolution frequently permits a high-definition view of the ET procedure which is highly reassuring both for the patient and the operator[20]. Our results showed that the total duration of ET was statistically significantly higher in the TV arm that come in line with the Bodri et al.[17] study. This is easily explained by the extra time needed to insert the vaginal probe and to obtain the correct sagittal plane of the uterus by slightly adjusting the position of the probe. TVUS, due to its higher resolution, frequently permits a high-definition view of the ET procedure which is highly reassuring both for the patient and the operator[21].


  Conclusion Top


There was no significant difference between TVS-guided ET and TAS-guided ET as regards clinical pregnancy rate. However, the duration of ET was statistically significantly longer in TVS. The patient discomfort intensity during ET was significantly higher in TAS-guided ET group and the TVS allowed better endometrial visualization at the time of ET.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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21.
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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