title: Techniques for preparation prior to embryo transfer.
abstract: BACKGROUND
  Embryo transfer (ET) is the final and most vulnerable step in in vitro fertilisation (IVF) treatment. Pregnancy rates after ET may be influenced by several factors including cervical preparation, the performance of a dummy or mock transfer, the choice of catheter, the use of ultrasound guidance, removing the mucus or blood on the catheter, and straightening of the utero-cervical angle. Recent research has focused on improving the embryo transfer technique in the hope of increasing the success rates of IVF. This review focused on preparation techniques as it is unclear whether these simple interventions will make ET an easier procedure with higher success rates and lower complication rates.
  
  
  OBJECTIVE
  To determine whether different preparation techniques prior to ET result in improved IVF outcomes.
  
  
  METHODS
  The Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO were searched (November 2008). The citation lists of relevant publications, reviews, and included studies were handsearched. Experts in the field were contacted to identify any unpublished trials.
  
  
  METHODS
  Only truly randomised controlled trials of the interventions straightening the utero-cervical angle, dummy transfer prior to ET, cervical and endometrial preparation, and embryo afterloading were included. The primary outcomes were live birth rate and pregnancy rate per woman randomised. Participants were women with any type of subfertility undergoing IVF treatment and reaching the ET stage.
  
  
  METHODS
  Two review authors critically appraised potentially eligible studies. Ten studies were included in this review and data were independently extracted by two review authors. Disagreements were resolved by discussion and involvement of a third author. Risk of bias was also independently assessed by two authors. Dichotomous outcome data were expressed as Peto odds ratios. Subgroup analysis and the investigation of heterogeneity were planned.
  
  
  RESULTS
  At the time of ET, there was no evidence of benefit with the following interventions: full bladder, removal of cervical mucus, flushing the endocervical canal or the endometrial cavity. We did not identify any eligible studies for dummy transfer, changing patient position, the use of a tenaculum, or embryo afterloading.
  
  
  CONCLUSIONS
  On the basis of the evidence in this review, no specific implications for practice are made. It is recommended, in general, that more, larger studies are done on ET preparation techniques. The studies need to be of a higher quality with better explained methods, more specified inclusion and exclusion criteria, and more participants.
authors.affiliation: Amsterdam Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands, 1100 DD.
authors.forename: Roos S
authors.initials: RS
authors.lastname: Derks
authors.forename: Cindy
authors.initials: C
authors.lastname: Farquhar
authors.forename: Ben Willem J
authors.initials: BW
authors.lastname: Mol
authors.forename: Karen
authors.initials: K
authors.lastname: Buckingham
authors.forename: Maas Jan
authors.initials: MJ
authors.lastname: Heineman
mesh_terms: D001723:Birth Rate; D002582:Cervix Mucus; D004624:Embryo Transfer / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D050498:Live Birth; D011247:Pregnancy; D011300:Preoperative Care / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome; D014599:Uterus / Q000033:anatomy & histology