Does Travelling After Embryo Transfer Affects The Pregnancy Outcome?

Introduction

The process of in vitro fertilization (IVF) involves many important steps. Embryo transfer (ET) is the final and most crucial step of IVF. The successful pregnancy outcome is predicted by the implantation of the embryo in the uterus.

The process of implantation involves two main components. First, a healthy embryo with the potential to implant. Second, a receptive endometrium that should enable implantation. The “cross-talk” between the embryo and the endometrium that eventually leads to apposition, attachment, and invasion of embryos is mandatory for successful implantation and subsequent normal placentation. [2.3].

Any abnormality related to the embryo, the endometrium, or the immune system will result in implantation failure. Therefore, travelling after embryo transfer per se will not affect any of the above factors responsible for the implantation of the embryo.

There have been major advances and improvements in ovulation induction, oocyte retrieval, and laboratory techniques, helping achieve the highest fertilization rates and embryo development. Recent results show at least one embryo transfer in 90% of all cases where oocytes have been retrieved (1).

Previously, many studies evaluated the effect of bed rest on pregnancy rates after embryo transfer. Below is the first study comparing pregnancy rates in patients who travelled to their countries with patients who stayed in Delhi after embryo transfer.

Materials and Methods

A retrospective analysis was done on 100 infertile females aged up to 40 years who underwent IVF from January 2016 to June 2016. The question we explored was: Is travelling safe after embryo transfer? And what were the effects of travelling on successful pregnancy rates?

They were divided into 2 groups—the females who travelled to their own country after 3 days of embryo transfer (48 females—Group 1) and those who remained in Delhi (52 females—Group 2).

The mean patient age, number of embryos transferred (1, 2, 3, 4), grade (A or B), easy or difficult transfer, and endometrial thickness are comparable in both groups.

Protocol

Ovarian stimulation was started on day 2 with gonadotropins, recombinant human FSH (rhFSH, Folisuge; Intas Pharmaceuticals Ltd, India, or Gonal F; Merck Serono S.p.A, Italy) or highly purified menotropin HMG (hpHMG, Menopur; Ferring GmbH, Germany) in the dose of 225 to 450 IU. 

The stimulation method and dose varied depending on the patient’s profile. Profile considerations included age, BMI, previous dose of gonadotropins, and date of menstrual cycle until day 6 of the period, followed by transvaginal follicular monitoring. The dose was adjusted according to ovarian response.

When follicles reached 13 to 14 mm, a daily subcutaneous injection of GnRH antagonist, 0.25 mg Cetrorelix (Cetrotide, Merck Serono S.p.A, Italy), was administered to trigger ovulation. Transvaginal oocyte aspiration was performed before 36 h, under ultrasound guidance, using a Wallace OPU needle and Cook’s gamete buffer media. Embryos were further cultured in Cook’s fertilization/cleavage/blastocyst media.

Embryo transfer was completed on Day 2 in all subjects under transabdominal USG guidance (with a full bladder).

After gentle insertion of the speculum and suction of cervical mucus, a soft outer sheath was inserted until the level of the internal os. Once at the internal os, they inserted the soft Cook’s Guardia Access echotip ET catheter containing embryos in 10 mcl media and 5 mcl air bubbles on both sides of the blastocyst media. 

After that, 3 or 4 embryos were placed in the mid-uterine cavity. Luteal support was added in the form of vaginal and injectable progesterone. Beta HCG was completed 14 days after the embryo transfer.

The institutional review board (IRB) didn’t approve this study. It was a retrospective study, and we collected the data after a positive pregnancy test result. The women involved in the trial stayed, or women travelling after embryo transfer to their home country.

Results

We summarized the demographic profile in Table 1. The embryo transfer parameters are shown in Table 2.

All parameters related to embryo transfer showed no significant difference between the groups. The groups were also compared to analyze whether they stayed in Delhi or they were travelling after embryo transfer by flight, and whether that variable affected the pregnancy rates (Table 3).

Discussion

In IVF treatments, rest for a varying period is commonly recommended after embryo transfer (ET). However, the scientific basis for this practice remains to be determined. In this context, we performed this research to investigate whether this advice about travelling after embryo transfer is sound or not. In our study, the pregnancy rates were higher in females who returned to their own country.

The implantation failure is the reason for IVF failure. Mechanical expulsion of the transferred embryo is also a possible cause of implantation failure. This may be the reason why most women are asked to stay in bed for several hours following ET. However, this has never been shown to be related to a higher success rate. It’s also noted that an immediate return to routine daily activities may lead to a decrease in maternal stress and anxiety following ET (4).

Studies have evaluated the effect of bed rest and mobilization following embryo transfer on the results of in vitro fertilization. For example, Gaikwad S et al. studied the influence of 10 minutes of bed rest after ET on the achievement of a live-born infant (LBI) in 240 recipients of IVF with donor eggs. The study showed that bed rest immediately after ET has no positive effect and can be negative for the outcome. There’s the potential that it’s due to an increase in stress levels (5).

Küçük M, also recommended that patients should not be encouraged to rest in bed after ET and should maintain their routine physical activities during IVF (6).

Li B et al. also performed a systematic review, concluding that there was insufficient evidence to support the routine use of bed rest to improve pregnancy outcome in women undergoing ET in IVF cycles (7). Their systematic review also analyzed the related literature, which examined each of the major steps of embryo transfer. In this review, 14 studies were included to assess whether bed rest or ambulation affects IVF pregnancy and live-birth rates. None of them demonstrated a benefit of bed rest after ET of any duration (8).

As you can see, many studies have been completed to evaluate the question: Is travelling safe after embryo transfer? Or is there an effect of bed rest on pregnancy rates after embryo transfer?. This is the first study to compare pregnancy rates in patients who travelled to their countries with those who stayed back after embryo transfer.

Conclusion

India is a growing destination for medical tourism. People from all over the globe are coming to our country for IVF treatment. We believe that encouraging patients to follow their daily routine immediately after ET or travelling after embryo transfer to their country may help them cope with anxiety. They may also feel more stress-free thanks to a more economical and comfortable life with the same cultural habits.

References

1. Gonen Y, Dirnfeld M, Goldman S, Koifman M, Abramovici H. Does the choice of catheter for embryo transfer influence the success rate of in vitro fertilization? Hum Reprod. 1991 Sep;6(8):1092-4.
2. Achache H, Revel A. Endometrial receptivity markers, the journey to successful embryo implantation. Hum Reprod Updat. 2006;12:731–46.
3. Fukui A, Funamizu A, Yokota M, Yamada K, Nakamua R, Fukuhara R, et al. Uterine and circulating natural killer cells and their roles in women with recurrent pregnancy loss, implantation failure, and pre-eclampsia. J Reprod Immunol. 2011;90:105–10.
4. Craciunas L, Tsampras N. Bed rest following embryo transfer might negatively affect the outcome of IVF/ICSI: a systematic review and meta-analysis. Human Fertility 2016; 19: 16-22.
5. Gaikwad S, Garrido N, Cobo A, Pellicer A, Remohi J. Bed rest after embryo transfer negatively affects in vitro fertilization: a randomized controlled clinical trial. Fertil Steril 2013;100:729–35, Level I.
6. Küçük, M. Bed rest after embryo transfer: is it harmful?. Eur J Obstet Gynecol Reprod Biol. 2013; 167: 123–126.
7. Li B, Zhou H, Li W. Bed rest after embryo transfer. European Journal of Obstetrics and Gynecology and Reproductive Biology 2011; 155(2): 125-128.
8. Practice Committee of the American Society for Reproductive Medicine. Performing the embryo transfer: a guideline. Fertil Steril. 2017;107:882–896.

Original Research Paper Published in the Global Journal for Research Analysis.

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