title: Assisted hatching on assisted conception (in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).
abstract: BACKGROUND
  Failure of implantation and conception may result from an inability of the blastocyst to escape from its outer coat, which is known as the zona pellucida. Artificial disruption of this coat is known as assisted hatching and has been proposed as a method for improving the success of assisted conception by facilitating embryo implantation.
  
  
  OBJECTIVE
  To determine the effect of assisted hatching (AH) of embryos from assisted conception on live birth and multiple pregnancy rates.
  
  
  METHODS
  We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (August 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (August 2012), MEDLINE (1966 to August 2012) and EMBASE (1980 to August 2012).
  
  
  METHODS
  Three authors identified and independently screened trials. We included randomised controlled trials (RCTs) of AH (mechanical, chemical or laser disruption of the zona pellucida prior to embryo replacement) versus no AH that reported live birth or clinical pregnancy.
  
  
  METHODS
  Three authors independently performed quality assessments and data extraction.
  
  
  RESULTS
  Thirty-one trials reported clinical pregnancy data, including 1992 clinical pregnancies in 5728 women. There was no significant difference in the odds of live birth in the AH group compared with the control group (9 RCTs; odds ratio (OR) 1.03, 95% confidence interval (CI) 0.85 to 1.26, moderate quality evidence), with no evidence of significant heterogeneity (P = 0.38) or inconsistency (I(2) = 6%). Analysis of the clinical pregnancy rates from the nine studies which reported live birth showed a non-significant result (OR 1.03, 95% CI 0.85 to 1.25 ).Analysis of all of the studies included in this update (31 RCTs) showed that the clinical pregnancy rate in women who underwent AH was slightly improved, but the level only just reached statistical significance (OR 1.13, 95% CI 1.01 to 1.27, moderate quality evidence). However, it is important to note that the heterogeneity for this combined analysis for clinical pregnancy rate was statistically significant (P = 0.001) and the I(2) was 49%. Subgroup analysis of women who had had a previous failed attempt at IVF found improved clinical pregnancy rates in the women undergoing AH compared with the women in the control group (9 RCTs, n = 1365; OR 1.42, 95% CI 1.11 to 1.81) with I(2) = 20%. Miscarriage rates per woman were similar in both groups (14 RCTs; OR 1.03, 95% CI 0.69 to 1.54, P = 0.90, moderate quality evidence). Multiple pregnancy rates per woman were significantly increased in women who were randomised to AH compared with women in the control groups (14 RCTs, 3447 women; OR 1.38, 95% CI 1.11 to 1.70, P = 0.004, low quality evidence).
  
  
  CONCLUSIONS
  This update has demonstrated that whilst assisted hatching (AH) does appear to offer a significantly increased chance of achieving a clinical pregnancy, the extent to which it may do so only just reaches statistical significance. The 'take home' baby rate was still not proven to be increased by AH. The included trials provided insufficient data to investigate the impact of AH on several important outcomes. Most trials still failed to report on live birth rates.
authors.affiliation: St Mary's Hospital, Department of Obstetrics and Gynaecology, Manchester, UK.
authors.forename: Sarah-Kate
authors.initials: SK
authors.lastname: Carney
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Das
authors.forename: Debbie
authors.initials: D
authors.lastname: Blake
authors.forename: Cindy
authors.initials: C
authors.lastname: Farquhar
authors.forename: Mourad M W
authors.initials: MM
authors.lastname: Seif
authors.forename: Linsey
authors.initials: L
authors.lastname: Nelson
mesh_terms: D010064:Embryo Implantation / Q000502:physiology*; D005260:Female; D005307:Fertilization in Vitro / Q000379:methods*; D006801:Humans; D011247:Pregnancy; D011256:Pregnancy Outcome; D018873:Pregnancy Rate; D016032:Randomized Controlled Trials as Topic; D020554:Sperm Injections, Intracytoplasmic / Q000379:methods; D015044:Zona Pellucida / Q000502:physiology*