**2. Materials and methods**

*Patients*. 35 patients between 22and 46 years of age undergoing IVF were included in this report. Informed consent was obtained prior to the start of the cycle. Controlled ovarian hyperstimulation was initiated with Follitropin (Follistim®, Organon Pharmaceuticals, Inc.). Endogenous gonadotropins surge (i.e., the prevention of an LH surge) was controlled with ganirelix acetate (Antagon™, Organon Pharmaceuticals, Inc.). Oocyte retrieval was carried out in an office setting under local anesthesia and mild sedation. Oocytes were fertilized and cultured in a human tubal fluid formulated medium at 37 degrees C and 5% CO2 in air". Embryos were transferred at 48-72 hours post fertilization (Figure 1a). All women received some type of luteal support, be it progesterone or hCG (3000 IU of hCG at 3 and 6 days post retrieval) (Figure 1b, c). Serum hCG was quantified at 10 days after the last hCG; a concentration of 5 IU/ml with a delayed menses was used as confirmation of pregnancy.

Description of Hysteroscopic Endometrial Embryo Delivery (HEED):

A transvaginal ultrasound of the uterus is performed and the direction and thickness of the endometrial lining is ascertained. With patient in dorsolithotomy position, a bivalved speculum is placed in the vagina and the cervix exposed. Vagina and cervix are washed with modified HAM's solution. Subsequently, 10 cc of 1% xylocaine is injected bilaterally in the utero-sacral nerve endings.

Fig. 1. Mini flexible hysteroscope (Storz®, LA, CA USA)

*Patients*. 35 patients between 22and 46 years of age undergoing IVF were included in this report. Informed consent was obtained prior to the start of the cycle. Controlled ovarian hyperstimulation was initiated with Follitropin (Follistim®, Organon Pharmaceuticals, Inc.). Endogenous gonadotropins surge (i.e., the prevention of an LH surge) was controlled with ganirelix acetate (Antagon™, Organon Pharmaceuticals, Inc.). Oocyte retrieval was carried out in an office setting under local anesthesia and mild sedation. Oocytes were fertilized and cultured in a human tubal fluid formulated medium at 37 degrees C and 5% CO2 in air". Embryos were transferred at 48-72 hours post fertilization (Figure 1a). All women received some type of luteal support, be it progesterone or hCG (3000 IU of hCG at 3 and 6 days post retrieval) (Figure 1b, c). Serum hCG was quantified at 10 days after the last hCG; a concentration of 5 IU/ml with a delayed menses was used as confirmation of

A transvaginal ultrasound of the uterus is performed and the direction and thickness of the endometrial lining is ascertained. With patient in dorsolithotomy position, a bivalved speculum is placed in the vagina and the cervix exposed. Vagina and cervix are washed with modified HAM's solution. Subsequently, 10 cc of 1% xylocaine is injected bilaterally in

Description of Hysteroscopic Endometrial Embryo Delivery (HEED):

Fig. 1. Mini flexible hysteroscope (Storz®, LA, CA USA)

**2. Materials and methods** 

the utero-sacral nerve endings.

pregnancy.

The cervix is grasped with an allis clamp and stabilized. Nitrogen gas is used as the distention media throughout the procedure via a hysteroscopic insufflator. A 3 mm flexible hysteroscope (Figure 1) loaded with embryo catheter containing the embryos (Figure 2) is then gently inserted through the cervical os under direct visualization of the cervical canal into the uterine cavity. Once the cavity is visualized, it is then further advanced to the fundus of the uterus. The loaded embryo transfer catheter (Precision Reproduction, LA, CA USA) is then advanced to 1.5 cm from the tip of the hysteroscope and placed over the point of embryo deposition, half way between the lowest point of the fundus in the midline and the tubal opening into the uterus (Figure 3). The embryos are then gently released by the embryologist. Our results show that hysteroscopic guided early embryo transfer results in a high pregnancy outcome, 2-3x greater than "blind" transfer technique rates. Direct visualization provides an objective, visually confirmed, replicable technique for embryo transfer. The end result is less operator dependent and in contrast to routine ET techniques in which operator experience may account for the variable overall pregnancy rates (Garcia 2002). Hysteroscopic direct embryo delivery may circumvent many of the known and previously reported embryo transfer related factors associated with poor outcomes. Many of our patients had failed prior IVF-ET attempts due to multiple etiologies.

Fig. 2. The flexible catheter for embryo delivery (Precision Reproduction, LLC. LA, CA USA)

A light weight flexible minihysteroscope was used for visualization of the endometrial cavity (Figure 1d) (Storz®, LA, CA USA). The scope incorporates a flexible distal end of 3mm in diameter with a straight through operating channel. In addition, the optic filter is directly connected to a light source, decreasing the weight of the scope and giving a better

Hysteroscopic Endometrial Embryo Delivery (HEED) 83

As may have been expected, the average age of patients for transfers on day 3 versus day 2 was lower (35 vs. 38 years of age), as they had better quality embryos which made it more feasible to continue embryo culture 1 day longer. Interestingly enough, the live pregnancy

Advantages of hysteroscopic guided direct embryo delivery include objectivity and replicability of the procedure. This unique and significant aspect of the procedure increases the reliability of correct entry into the uterine cavity with direct visual confirmation. Furthermore, placement and subsequent implantation at a precise location, with minimal volume of transfer media, provides an obvious benefit to patients with distorted uterine cavities, myomas, and adenomyosis and uterine adhesions. Visualization also provides the advantage of maneuvering along the contours of the uterus, thus decreasing the rate of trauma to the endometrial lining. In addition, performing gas distension of the uterus by an inert gas (N2), the catheter tip is less likely to come into contact with the uterine fundus

stimulating uterine contractions and creating an unfavorable environment for implantation (Kovacs 1999, Lesny 1998). It has been reported that high frequency uterine contractions are associated with a lower ongoing clinical pregnancy rate and complete expulsion of the embryo (Fanchin 1998). It has also been postulated that the expulsion of the embryo into the lower uterine segment may result in higher rates of cervical ectopic pregnancy and placenta

Witnessing uterine contractions hysteroscopically can also guide the clinician to abort and defer the procedure, thus decreasing costs, multiple failed attempts of ET, embryo loss, and risk of cervical ectopics and placenta previas. Direct visualization of the catheter tip ensures that the embryos are not retained in the catheter or lost. Viser et al. found a lower pregnancy rate when retained embryos were present (3% vs. 20.3%). In addition, catheter tip visualization allowed us to deliver smaller aliquot volumes for ET (5µl) as opposed to routine volumes (30µl). Smaller volume allows better handling of the embryo for proper orientation to the uterine lining, stabilizing the position and has been reported to increase pregnancy and implantation rates (Meldrum 1987). It may also contribute to the reduced

**Total Start** 22 13 **Cancelled** 0 0 **Retrievals** 22 13 **Transfers** 22 13 **Total + Beta** 9 7 **Chemical Preg** 2 0 **Spotaneous ab** 3 2 **Multiple Preg** 3 1 **Ectopic preg** 1 1 **LiveBorn** 3(13%) 4(30%)

Table 1. Results from HEED on day2 and day 3 transfers

rate was also higher in day 3 transfers (31% vs. 15% ).

**4. Discussion** 

which has been associated with

previas (Romundstad 2006; Schoolcraft 2001).

**Day 2 Transfer Day 3 Transfer**  average age 3835 average age 38

"feel" for the scope. The transfer catheter (Precision Reproduction, LLC, LA, CA USA) is polycarbonate based with a tapered tip (to 500 m), beveled to 60o.

Fig. 3. Placement of embryo(s) under hysteroscopic guidance; arrow points to the tip of the catheter; catheter entry at 8 o'clock position.
