**2.2. Description of hysteroscopic implantation**

A lightweight flexible mini- hysteroscope (Storz™) was used for visualization of the endometrial cavity (Fig 1D). 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. Nitrogen gas instead of CC2 is used for uterine distention. Nitrogen gas is inert and is used in the trimixture of Nitrogen, Cxygen and Carbon Dioxide utilized for embryo culture in an IVF laboratory. Gas pressure is set at max 70 mm mercury (HG). A maximum of 50 cc of gas is used

during the entire procedure. The transfer catheter is polycarbonate based with a tapered tip (to 500 µm), beveled to 45-60° (Initially made by Cook CB/GYN™, Spencer, Indiana, USA and subsequently made by Precision Reproduction, LLC Los Angeles, CA 90212 USA). The catheter is inserted to a distance of 0.5cm horizontally and to a depth of approximately 1mm below the surface of the endometrium, and 2 cm away from the junction of tuboendometrial border as observed hysteroscopically where the endometrium is thickest as seen through the hysteroscope. The embryo(s) is deposited under direct hysteroscopic visualization (Fig 1D) using a 100 µl Hamilton syringe (Hamilton Company; Nevada, USA). No more than 2 embryos were implanted at any one site.

146 Enhancing Success of Assisted Reproduction

**2. Materials and methods** 

confirmation of pregnancy.

The study was approved by local review board at West Coast IVF Clinic, Inc. and a fully informed consent was obtained from all patients. There were 21 consecutive patients between 34-50 years of age with a diagnosis of peri/postmenopause or premature ovarian failure with or without tubal disease. They underwent 24 fresh IVF cycles in this study. Controlled ovarian hyperstimulation was initiated with follitropin � (FollistimC, Crganon Pharmaceuticals, Inc.). Premature surge of endogenous gonadotropins were controlled with ganirelix acetate (AntagonC, Crganon Pharmaceuticals, Inc.). Cocyte retrieval was carried out in an office setting under local anesthesia and mild sedation. Embryo culturing was performed using sequential media (G1 and G2; Vitrolife, or Early Cleavage MediumC supplemented with SSS and Complete Multiblast MediumC with SSS; Irvine Scientific, USA) to day five or six. Up to 2 grade 1 expanded/hatching blastocysts were transferred (Fig 1A). Recipients were down regulated with long acting GnRH analog (Leuprolide acetate Depot, Abbott, USA). The endometrium was primed with Estradiol 2 mg tid until the day of donor egg retrieval, when it was continued or reduced to 1 mg tid. Luteal support was maintained with Progesterone in oil IM 50-100 mg/progesterone vaginal tablets (EndometrinC, Ferring, USA), 100 mg tid. until the day of Pregnancy test. If the test was positive progesterone was continued through the 8th week of pregnancy or sooner until a

Serum human chorionic gonadotropin (hCG) was quantified on the tenth or eleventh day after SEED was performed on day six or five after retrieval, respectively. Although the assay sensitivity for detection of hCG was at 2 IU/ml a concentration of >5 IU/ml was used for

A lightweight flexible mini- hysteroscope (Storz™) was used for visualization of the endometrial cavity (Fig 1D). 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. Nitrogen gas instead of CC2 is used for uterine distention. Nitrogen gas is inert and is used in the trimixture of Nitrogen, Cxygen and Carbon Dioxide utilized for embryo culture in an IVF laboratory. Gas pressure is set at

during the entire procedure. The transfer catheter is polycarbonate based with a tapered tip (to 500 µm), beveled to 45-60° (Initially made by Cook CB/GYN™, Spencer, Indiana, USA and subsequently made by Precision Reproduction, LLC Los Angeles, CA 90212 USA). The catheter is inserted to a distance of 0.5cm horizontally and to a depth of approximately 1mm below the surface of the endometrium, and 2 cm away from the junction of tuboendometrial border as observed hysteroscopically where the endometrium is thickest as seen through the

rise in serum progesterone was noted as the pregnancy progressed.

**2.2. Description of hysteroscopic implantation** 

max 70 mm mercury (HG). A maximum of 50 cc of gas is used

**2.1. Patients** 

**Figure 1.** Stages of subendometrial embryo transfer. Expanded hatching blastocyst (A); estrogenic endometrium (B); progestational endometrium (C); subendometrial embryo transfer (D); early gestational sac at 5 weeks (E); fetus at 6 weeks (F).
