Abstract: We included four RCTs (n = 1392 women) which administered the following interventions: bed rest (two trials), fibrin sealant (one trial), and mechanical closure of the cervix (one trial). Our primary outcome, live birth rate, was not reported in any of the included trials; nor were the data available from the corresponding authors. For the ongoing pregnancy rate, two trials comparing more bed rest with less bed rest showed no evidence of a difference between groups (odds ratio (OR) 0.88; 95% confidence interval (CI) 0.60 to 1.31, 542 women, I2 = 0%, low quality evidence). Secondary outcomes were sporadically reported with the exception of the clinical pregnancy rate, which was reported in all of the included trials. There was no evidence of a difference in clinical pregnancy rate between more bed rest and less bed rest (OR 0.88; 95% CI 0.60 to 1.31, 542 women, I2 = 0%, low quality evidence) or between fibrin sealant and usual care (OR 0.98; 95% CI 0.54 to 1.78, 211 women, very low quality evidence). However, mechanical closure of the cervix was associated with a higher clinical pregnancy rate than usual care (OR 1.92; 95% CI 1.40 to 2.63, very low quality evidence). The quality of the evidence was rated as low or very low for all outcomes. The main limitations were failure to report live births, imprecision and risk of bias. Overall, the risk of bias of the included trials was high. The use of a proper method of randomisation and allocation concealment was fairly well reported, while only one trial clearly reported blinding. There was no evidence that any of the interventions had an effect on adverse event rates but data were too few to reach any conclusions. There is insufficient evidence to support any specific length of time for women to remain recumbent, if at all, following embryo transfer, nor is there sufficient evidence to recommend the use of fibrin sealants added to the embryo transfer fluid. There is very limited evidence to support the use of mechanical pressure to close the cervical canal following embryo transfer. Further well-designed and powered studies are required to determine the true effectiveness and safety of these interventions.

Plain-language summary: Following meticulous searches of major databases (all databases searched June 2013, MDSG register last searched June 2014) and conference proceedings we were able to locate four trials, with a total of 1392 women. These were all prospective, randomised controlled trials comparing two competing post-ET interventions or an intervention versus no treatment on clinical outcomes in women undergoing IVF and ICSI. Each study recruited from 164 to 639 infertile women of reproductive age and all were conducted in IVF centres; none of them had conflicts of interest regarding study funding. Our primary measure of success, live birth rate, was not reported in any of the included trials. There was insufficient evidence to support a specific length of time for women to remain recumbent, if at all, following ET, nor was there sufficient evidence to recommend the use of fibrin sealants. There was very limited evidence to support the use of mechanical pressure to close the cervical canal. Further large well-designed studies are required to determine the true effectiveness and safety of these interventions. There was no evidence that any of the interventions had an effect on adverse event rates, but data were too few to reach any conclusions. The quality of the evidence was low or very low for all comparisons. The main limitations were failure to report live births, imprecision and risk of bias. Study risk of bias was variable, with the reporting of a proper method of randomisation and allocation concealment demonstrated in most trials while only one trial clearly blinded both the patients and the clinicians to the intervention received.