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 !!. - PowerPoint PPT PresentationTRANSCRIPT
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Tehnika embrio transfera i Tehnika embrio transfera i uspjeh IVF-auspjeh IVF-a
Renato BaumanRenato Bauman
KB Sveti DuhKB Sveti DuhKlinika za ginekologiju i porodništvoKlinika za ginekologiju i porodništvo
Zagreb, CroatiaZagreb, Croatia
VIII Hrvatski kongres o humanoj reprodukciji, Brijuni VIII Hrvatski kongres o humanoj reprodukciji, Brijuni 10.09.2011.10.09.2011.
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Embrio transfer – “evidence based” Embrio transfer – “evidence based” pristuppristup
85% prenešenih 85% prenešenih zametaka se ne zametaka se ne implantira implantira
Točan uzrok ostaje Točan uzrok ostaje nepoznat !! nepoznat !!
Mogući uzroci Mogući uzroci neimplantacije:neimplantacije:
1.1. Tehnika ETTehnika ET2.2. Receptivnost Receptivnost
endometrijaendometrija3.3. Sposobnost zametka za Sposobnost zametka za
implantacijuimplantaciju
Edwards RG 1995 Hum reprod
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Embrio transfer – EB - Tehnika ETEmbrio transfer – EB - Tehnika ET
Prema randomiziranim studijama i meta-Prema randomiziranim studijama i meta-analizama samo tri postupka mogu analizama samo tri postupka mogu utjecati na poboljšavanje stope utjecati na poboljšavanje stope implantacijeimplantacije
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ET pod UZV kontrolomET pod UZV kontrolom
Sallam HN, Fertil Steril 2003 DAAbou-Setta AM, Fertil Steril 2007 DABrown J, Cochrane Database 2010 DA
Drakeley AJ, Hum Reprod 2008 NE!!!
Pun mjehur !!??
Embrio transfer – EB - Tehnika ETEmbrio transfer – EB - Tehnika ET
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Embrio transfer – EB - Tehnika ETEmbrio transfer – EB - Tehnika ET
Prijenos zametaka 15-20 mm ispod Prijenos zametaka 15-20 mm ispod
fundusafundusa
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!
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ETET
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Embrio transfer – EB - Tehnika ETEmbrio transfer – EB - Tehnika ET
Probni (“DUMMY”) ET prije “stvarnog”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 fertilizationFertil Steril 1990.
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Izbor katetera ?Izbor katetera ?
Coroleu B, Hum Reprod 2006Abou-Setta AM, Hum Reprod 2005 SOFT!
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Embrio transfer – EB - Tehnika ETEmbrio transfer – EB - Tehnika ET
Randomizirane studije ukazuju da slijedeći Randomizirane studije ukazuju da slijedeći postupci NEMAJU utjecaja na implantacijupostupci NEMAJU utjecaja na implantaciju
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ispiranje cervikalnog kanala s medijemispiranje cervikalnog kanala s medijem
Sallam HN et al The importance of flushing the Sallam HN et al The importance of flushing the cervical canal with culture medium prior to embryo cervical canal with culture medium prior to embryo transfer. Fertil Steril 2000transfer. Fertil Steril 2000
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Ostavljanje katetera intrauterino kroz 30 Ostavljanje katetera intrauterino kroz 30 sekundisekundi
Martinez F et al. Ultrasound-guided embryo transfer:Immediate withdrawal of the catheter versus a 30-seconds wait. Hum Reprod 2001
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Mirovanje u krevetu poslije ETMirovanje 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
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Antibiotici poslije ETAntibiotici poslije ET
Učinak držanja cerviksa hvataljkom Učinak držanja cerviksa hvataljkom
Egbase PE et al. Prophylactic antibiotics andEndocervical microbial inoculation of the endometrium at ET. Lancet, 1999.
Brook N et al. A randomized control trial of prophylactic antibiotics prior to ET. Hum Reprod2006
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ET !ET !
Krv u kateteru i boravak zametaka duže Krv u kateteru i boravak zametaka duže od 120 sekundi u kateteru značajno od 120 sekundi u kateteru značajno smanjuje stopu implantacije!smanjuje stopu implantacije!
Zrak u kateteru, dva transfera u istom Zrak u kateteru, dva transfera u istom ciklusu, mirovanje, spolni odnos nakon ciklusu, mirovanje, spolni odnos nakon prijenosa zametaka ni korištenje prijenosa zametaka ni korištenje sildenafila ne utječu na rezultat prijenosa sildenafila ne utječu na rezultat prijenosa zametakazametaka
Sallam HN Curr Opin Obstet Gynecol 2005Alvero R, Hum Reprod 2003
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Kvaliteta zametakaKvaliteta zametaka
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Receptivnost endometrijaReceptivnost endometrija
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•
Ocjena receptivnosti Ocjena receptivnosti
endometrijaendometrija
- - debljina endometrija (volumen debljina endometrija (volumen
3D)3D)
- - ehogenost endometrijaehogenost endometrija
- - prokrvljenost endometrijaprokrvljenost endometrija (CD)(CD)
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Uterine Profile
Score
Endometrial thickness <7 mm 7 mm
0 3
Endometrial morphology Triple line Others
3 0
Myometrial echogenicity Homogeneous Non-homogeneous
1 0
Uterine artery pulsatility index 3 >3
4 0
Protodiastolic notch Present Absent
0 2
End-diastolic flow blood Present Absent
4 0
Spiral artery blood flow (color or power Doppler)
Present Absent
3 0
Total 20
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Prije IVF-a (ET) provjeriti UTERUS Prije IVF-a (ET) provjeriti UTERUS s TVCD (bolje s 3D)s TVCD (bolje s 3D)
PolipiPolipi
AnomalijeAnomalije
Submukozni miomiSubmukozni miomi
Intrauterine prirasliceIntrauterine priraslice
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UTERUS SUBSEPTUS
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Jajovodi!Jajovodi!
Saktosalpinks – Saktosalpinks – neprijatelj implantacije neprijatelj implantacije – prethodno – prethodno salpingektomija ili salpingektomija ili koagulacija istmičnog koagulacija istmičnog dijela tubedijela tube
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Tanki endometrijTanki endometrij
< 8 mm< 8 mmOdgoditi transfer do 5 dana ili Odgoditi transfer do 5 dana ili
kripohraniti zametke i prijenos u kripohraniti zametke i prijenos u slijedećem prirodnom ciklususlijedećem prirodnom ciklusu
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LijekoviLijekovi
NSANSA
Diazepam?Diazepam?
PROGESTERON vaginalno, HCG, aGnRHPROGESTERON vaginalno, HCG, aGnRH
E2 (2x1 mg)? Do 8 mg/dan??? E2 (2x1 mg)? Do 8 mg/dan???
ASPIRIN 1 mg/kg?ASPIRIN 1 mg/kg?
NMH (doza?, trajanje?)NMH (doza?, trajanje?)
Kortikosteroid (doza?, trajanje?)Kortikosteroid (doza?, trajanje?)
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ALTERNATIVE ?ALTERNATIVE ?
GINKOGINKO
AKUPUNKTURAAKUPUNKTURA
HISTEROSKOPIJAHISTEROSKOPIJA
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Optimizing the technique of embryo Optimizing the technique of embryo transfer transfer Lindsay Mains Fertil Steril 2010Lindsay Mains Fertil Steril 2010
SummarySummary
Evidence-based GuidelinesEvidence-based Guidelines
1. Effort should be made to avoid “difficult” transfers.1. Effort should be made to avoid “difficult” transfers. 2. Ultrasound guidance will result in easier transfers with improved outcomes.2. Ultrasound guidance will result in easier transfers with improved outcomes. 3. Soft catheters should be used when feasible.3. Soft catheters should be used when feasible.
Recommendations Based on Expert OpinionRecommendations Based on Expert Opinion
1. Trial transfers allow better preparation for difficult transfers.1. Trial transfers allow better preparation for difficult transfers. 2. Cervical mucus should be removed to potentially decrease bacterial 2. Cervical mucus should be removed to potentially decrease bacterial
contamination and mucus plugging of the catheter.contamination and mucus plugging of the catheter. 3. Embryos should be deposited in the midportion of the uterus.3. Embryos should be deposited in the midportion of the uterus. 4. Negative pressure should be minimized during withdrawal of the catheter.4. Negative pressure should be minimized during withdrawal of the catheter. 5. The procedure should be done in a minimum amount of time.5. The procedure should be done in a minimum amount of time.
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