An embryo transfer is the final medical step in an IVF treatment cycle. It is the culmination of this treatment as the embryos are essentially the end-product of the IVF laboratory. Typically, a good IVF clinic that has a good IVF lab generates good quality embryos. After these have been transferred to the woman’s uterus, the doctor’s role just reaches an end and only nature has a role to play in whether and how the embryos will grow in the uterus.

Embryo transfer is one procedure in IVF that has consistently been underestimated and undervalued; this is because it seems too easy as there is no surgery involved. In my opinion, this is the most important step of the entire IVF, as it is the one aspect that can make or break the treatment.

The steps

Its not too difficult to teach a junior doctor how an egg collection is done, but it can be very tough to master the skill of embryo transfer, as it seems just too easy when an expert is doing it. These are the embryo transfer steps:

• The vagina is cleaned with large amounts of normal saline
• Mucus sticks are used to remove as much cervical mucus as we can. Removing too much can be detrimental as it can cause bleeding and its important to be cautious
• We try not to use a tenaculum or a vulsellum. The axis of the uterus has to be straightened out; we preferably use a sponge holder or a Cusco's speculum blade.
• The loaded catheter is then gently inserted
• After a wait of 1 minute, the syringe is plunged and then we wait for another minute. Its important not be in a hurry to complete the transfer

We ask the patient either to breathe slowly, meditate or pray while the transfer is being done. At times, it also helps to distract the patient and it is important for the doctor to be calm and collected. In fact, I always tell junior doctors that they should take a few very deep breaths before they insert the catheter.

Important things

• The feel that the catheter has gone thru the internal os
• We prefer using ultrasound guidance as this allows us to check the catheter is in the right place. It can also be very reassuring for patients to see the "flash" in the cavity, so they are sure their embryos are being deposited safely in their uterus !
• Once the catheter is introduced, it shouldn’t touch the fundus. If you feel you have touched the fundus, withdraw a little immediately!
• Its important to measure the uterocervical length when doing a dummy transfer
• The direction that the catheter is introduced is very important as well. As far as possible, it shouldn’t touch the walls of the uterus
• At times, if you have applied excessive force , you might feel the catheter is going in; but its actually it is kinking 7 starts recoiling. Its important to be gentle with the patient and take your time.
• The catheter that is used should be as soft as possible
• Its best to use one particular brand, as it will help you get used to it and you get a good sense of how it behaves.
• For difficult transfers, you may have to use a special catheter set, with an introducer.

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