Tehnika embrio transfera i uspjeh ivf a
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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. 85% prenešenih zametaka se ne implantira Točan uzrok ostaje nepoznat !!.

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Tehnika embrio transfera i uspjeh IVF-a

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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.


85% prenešenih zametaka se ne implantira

Točan uzrok ostaje nepoznat !!

Mogući uzroci neimplantacije:

Tehnika ET

Receptivnost endometrija

Sposobnost zametka za implantaciju

Embrio transfer – “evidence based” pristup

Edwards RG 1995 Hum reprod


Embrio transfer – EB - Tehnika ET

  • Prema randomiziranim studijama i meta-analizama samo tri postupka mogu utjecati na poboljšavanje 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 bliže 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 slijedeći 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 poslije ET

  • 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 !

  • Krv u kateteru i boravak zametaka duže od 120 sekundi u kateteru značajno smanjuje stopu implantacije!

  • 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)


Prije IVF-a (ET) provjeriti UTERUS s TVCD (bolje s 3D)

  • Polipi

  • Anomalije

  • Submukozni miomi

  • Intrauterine priraslice


UTERUS SUBSEPTUS


Jajovodi!

  • 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


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.


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