P-315 To study the efficacy of Transvaginal ultrasound-guided Embryo Transfer over Transabdominal ultrasound-guided Embryo Transfer in transfers with poor visibility due to obesity or marked retroversion
Authors: Jha B , Singh P 
Published: June 2023

Abstract

Study question
Why is Transvaginal guided embryo transfer,understudied and underutilised in difficult cases of embryo transfers with compromised visibility of uterine canal in Transabdominal ultrasound ?

Summary answer
In patients with poor visibility of uterine canal using TAUS due Obesity, retroveted uterus,PID,pelvic adhesions, endometriosis, TVUS-ET gives significantly higher clinical Pregnancy rates.

What is known already
TAUS-ET is most popular method of Embryo transfer worldwide. Despite the benefits , this procedure also presents some important drawbacks. Firstly, TAUS-guided ET requires an assistant to operate the transducer while physician performs ET procedure. Moreover, patient needs to fill her urinary bladder to enable visualization of uterine canal, which causes discomfort and sometimes uterine cramping during ET, which in turn can negatively impact implantation rates.TVUS is the main technique used in all other gynecological investigations. Because of high frequency and close proximity to target area, TVUS transducers provide better resolution of the uterocervical angle and improved overall image quality.

Study design, size, duration
This retrospective study was conducted to compare efficacy of TVUS-guided ET to conventional TAUS-guided ET in difficult transfers, who underwent treatment at Triveni IVF, Darbhanga, India between November 2020 to December 2022. It was based on data extracted from records of all women who underwent difficult TAUS-ET procedure between Nov 2020 to Nov 2021.Data from records of matching number of women who underwent TVUS-ET procedure between Dec 2021 to Dec 2022 were used for comparison.

Participants/materials, setting, methods
All were ICSI and FET transfers.
Inclusion criteria: (1) All included between 25–35 years of age with difficult visualisation of uterine canal during TAUS-Mock ET in previous cycle (2) BMI ≥ 30; (3) Retroverted uterus due to any underlying pathology 4)All pts included had good ovarian reserve; (4) unexplained infertility &gt;3 years. Exclusion criteria: (1) severe male factor infertility, (2) any intrauterine factor of infertility (3) ovarian endometrioma or PCOS and (5) multiple ICSI failure (&gt;3 trials).

Main results and the role of chance
Total of 123 cycles,61 guided by TVUS (Group 1) and 62 TAUS (Group 2) were included. Our results showed significantly higher Clinical Pregnancy rate in TVUS group as compared to TAUS group, in difficult transfers (43.3% vs. 36.1 % p = 0.0045). VAS (visual analog scale) of the pain during ET was significantly less in TVUS group in comparison to TAUS group (17% vs 64% p = 0.0001), also the abdominal discomfort was significantly less in TVUS group in comparison to TAUS group (11% vs. 69 % p = 0.0001).
TVUS-ET group showed significantly higher CPR as it has better resolution due to proximity to target organs allowing proper visualization of catheter tip especially in cases with obesity and marked uterine retroversion.TVUS has superior role in cases with difficult transfer because it can easily analyze the cause of difficult transfers as endocervical crypts, marked anteverted uterus, cervical canal tortuosity.
Another advantage of TVUS is requiring emptied urinary bladder in contrast to TAUS. Full bladder is both time consuming and causes abdominal discomfort and uterine cramps leading to increased patient anxiety.As regards to abdominal discomfort and uterine cramps, there was extremely high statistical significance between the two groups in our study.

Limitations, reasons for caution
Despite the wide benefits,TVUS-ET has not been widely adopted, on account of difficulty in manipulating ET catheter and vaginal transducer simultaneously in very constricted area.Other comfortable approaches that may assist physicians such as inner catheter can be pushed by embryologist while physician holds TVS-probe and outer catheter in place.

Wider implications of the findings
The results suggested that TVUS-guided ET was better in difficult transfers with poor visibility of uterine canal in studied sample. This technique presented deserves consideration for wider use since it can offer better visualization, excellent comfort to patients during the procedure, and requires only one operator.

Trial registration number
Not applicable