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• W2601095682 abstract "A systematic review of the literature was conducted which examined each of the major steps of embryo transfer. Recommendations made for improving pregnancy rates are based on interventions demonstrated to be either beneficial or not beneficial. A systematic review of the literature was conducted which examined each of the major steps of embryo transfer. Recommendations made for improving pregnancy rates are based on interventions demonstrated to be either beneficial or not beneficial. Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/14713-23759 Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/14713-23759 One of the most critical steps in the process of in vitro fertilization (IVF) is the embryo transfer. Studies have consistently demonstrated that embryo transfer pregnancy rates differ depending upon the clinician performing the procedure (1Karande V.C. Morris R. Chapman C. Rinehart J. Gleicher N. Impact of the ‘physician factor’ on pregnancy rates in a large assisted reproductive technology program: Do too many cooks spoil the broth?.Fertil Steril. 1999; 71 (Level II-2): 1001-1009Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 2Hearns-Stokes R.M. Miller B.T. Scott L. Creuss D. Chakraborty P.K. Segars J.H. Pregnancy rates after embryo transfer depend on the provider at embryo transfer.Fertil Steril. 2000; 74 (Level II-2): 80-86Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 3Angelini A. Brusco G.F. Barnocchi N. El-Danasouri I. Pacchiarotti A. Selman H.A. Impact of physician performing embryo transfer on pregnancy rates in an assisted reproductive program.J Assist Reprod Genet. 2006; 23 (Level II-2): 329-332Crossref PubMed Scopus (21) Google Scholar). In addition, data are accumulating that demonstrate a paucity of training in current fellowship programs or for practitioners who may have embryo transfer success rates consistently below the mean. A recent survey of Society for Assisted Reproductive Technology (SART) medical directors demonstrates that essentially all practitioners are allowed to perform embryo transfer if they desire, no matter what their skill (4Toth T.L. Lee M.S. Bendikson K.A. Reindollar R.H. Embryo Transfer Techniques: An ASRM Survey of Current SART Practices.Fertil Steril. 2017; 107 (Level II-2): 1003-1011Abstract Full Text Full Text PDF Google Scholar). Half of the programs allow clinicians to perform embryo transfer using their personal “procedure” rather than having a standard protocol for all clinicians to follow. The results of that comprehensive survey demonstrate the breakdown of responses for 84 questions. From that survey, steps were identified for which the majority of practitioners demonstrated concordance, others were found to have nearly equal discordance, and, for most, a few outliers were identified. From those data a Common Practice Protocol was developed (4Toth T.L. Lee M.S. Bendikson K.A. Reindollar R.H. Embryo Transfer Techniques: An ASRM Survey of Current SART Practices.Fertil Steril. 2017; 107 (Level II-2): 1003-1011Abstract Full Text Full Text PDF Google Scholar). The purpose of this guideline for performing embryo transfer is to examine the various steps of the Common Practice Protocol by a systematic review of the literature to determine which of the steps, if any, are supported by sufficient data. This clinical practice guideline was based on a systematic review of the literature. A systematic literature search of relevant articles was performed in the electronic database MEDLINE through PubMed in December 2016, with a filter for human subject research. No limit or filter was used for time period or English language, but articles were subsequently culled for English language. A combination of the following medical subject headings or text words/keywords were used: acupuncture; acupuncture therapy; afterloading; ambulation; analgesia; analgesic; analgesics; anesthesia; anti anxiety; antibacterial hand soaps; antibiotic; antibiotics; antibiotic prophylaxis; bed rest; bedrest; birth; bleeding; blastocyst transfer; blood; catheter; catheter remains; catheter remnants; catheterization; catheterization/adverse effects; catheterization/methods; cervix; Chinese medicine; cleanse; cleanser; cleansing; deposition; disinfection; duration; ejection; embryo retention; embryo transfer; embryo transfer catheter; embryo transfer/instrumentation; embryo transfer/methods; embryo transfer protocol; embryo transfer techniques; endometrial; endometrial cavity; endometrium; expel; expulsion; flushing; gloves; hand disinfection; hand hygiene; hand washing; hand washing/behavior; hand washing/behaviors; hand disinfectant; hand disinfectants; hand washing/glove; implantation; injection; in vitro fertilization; IVF; load; loading; massage; medicine, Chinese traditional relaxant; mucus; mucous; physician; physician's role; placement; plunge; plunger; pregnancy; pressure; recumbency; recumbent; recumbent position; recumbent posture; release; replacement; rest; retained embryos; sedation; simulation; skin scrub; speed; stiletto; stylet; stylette; success; success rate; supine; surgical gloves; surgical scrub; time; time factors; time interval; transcutaneous electrical acupoint stimulation; transcutaneous electrical nerve stimulation; transfer techniques; ultrasound; ultrasound guidance; ultrasound guided embryo transfer; uteri; uterus; vaginal flush; vaginal preparation. Initially, titles and abstracts of potentially relevant articles were screened and reviewed for inclusion/exclusion criteria. Protocols and results of the studies were examined according to specific inclusion criteria. Only studies that met the inclusion criteria were assessed in the final analysis. Studies were eligible if they met one of the following criteria: level I or II studies that assessed the effectiveness of a procedure correlated with an outcome measure (pregnancy, implantation, or live-birth rates); meta-analyses; and relevant articles from bibliographies of identified articles. This guideline focuses principally on pregnancy rate since most of the studies report pregnancy rates rather than live-birth rates. Three members of an independent task force reviewed the full articles of all citations that possibly matched the predefined selection criteria. Final inclusion or exclusion decisions were made on examination of the articles in full. Disagreements about inclusion among reviewers were discussed and solved by consensus or arbitration after consultation with an independent reviewer/epidemiologist. The quality of the evidence was evaluated using the following grading system and is assigned for each reference in the bibliography:Level I: Evidence obtained from at least one properly designed randomized, controlled trial.Level II-1: Evidence obtained from well-designed controlled trials without randomization.Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.Level III: Opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees. Systematic reviews/meta-analyses were individually considered and included if they followed a strict methodological process and assessed relevant evidence. The strength of the evidence was evaluated as follows:Grade A: There is good evidence to support the recommendation, either for or against.Grade B: There is fair evidence to support the recommendation, either for or against.Grade C: There is insufficient evidence to support the recommendation, either for or against. Number of studies identified in electronic search and from examination of reference lists from primary and review articles: 2,086. Number of studies included: 143. When current meta-analyses were not available to combine existing data, selected meta-analyses of studies were performed by the American Society for Reproductive Medicine (ASRM) Practice Committee to estimate the pooled relative risk (RR) ratios of outcomes of interest. Statistical analyses and construction of forest and funnel plots were performed with Stata version 12.1. RR ratios, and 95% confidence intervals (CIs) were calculated for each outcome. Random effects models were used for the meta-analyses. Heterogeneity was assessed with the use of the I2 test. Publication bias was assessed by constructing funnel plots. Tables listing inclusion/exclusion criteria are available online as Supplemental Material. Over the past two decades there has been significant interest in maximizing assisted reproductive technology (ART) pregnancy rates through enhancing patient preparation prior to embryo transfer. These attempts have included acupuncture, analgesics, anesthesia, massage, transcutaneous electrical acupoint stimulation (TEAS), whole-systems traditional Chinese medicine (WS-TCM), and prophylactic antibiotics. These interventions provide theoretical benefits, which include modulating hormones, altering energy flow throughout the body, enhancing blood flow to the uterus, reducing stress, and reducing microbial colonization of the genital tract. Acupuncture has been the focus of significant interest and research, as it is an important tradition in Chinese medicine that dates back over 3,000 years. Acupuncture involves the insertion of fine needles through the skin intended to alter the flow of energy throughout the body. There are a variety of different acupuncture protocols based upon the underlying diagnosis. Protocols can include varying acupuncture points and treatment intervals during ovarian stimulation, retrieval, and before and after transfer. A review of the medical literature is challenging as there is no consensus regarding a particular acupuncture protocol, and studies vary in regard to their inclusion and exclusion criteria, investigator blinding, and treatment of the control groups, including sham acupuncture. A number of randomized controlled trials (RCTs) on acupuncture have been published with contradictory results. There are five RCTs showing some benefit of acupuncture (5Domar A.D. Meshay I. Kelliher J. Alper M. Powers R.D. The impact of acupuncture on in vitro fertilization outcome.Fertil Steril. 2009; 91 (Level I): 723-726Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 6Paulus W.E. Zhang M. Strehler E. El-Danasouri I. Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy.Fertil Steril. 2002; 77 (Level I): 721-724Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 7Qu F. Zhang D. Chen L.T. Wang F.F. Pan J.X. Zhu Y.M. et al.Auricular acupressure reduces anxiety levels and improves outcomes of in vitro fertilization: a prospective, randomized and controlled study.Sci Rep. 2014; 4 (Level I): 5028PubMed Google Scholar, 8Rashidi B.H. Tehrani E.S. Hamedani N.A. Pirzadeh L. Effects of acupuncture on the outcome of in vitro fertilisation and intracytoplasmic sperm injection in women with polycystic ovarian syndrome.Acupunct Med. 2013; 31 (Level I): 151-156Crossref PubMed Google Scholar, 9Westergaard L.G. Mao Q. Krogslund M. Sandrini S. Lenz S. Grinsted J. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial.Fertil Steril. 2006; 85 (Level I): 1341-1346Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Anxiety levels were lower (P<.05) and clinical pregnancy, implantation, and live-birth rates were higher (P<.017) in the auricular acupuncture groups vs the sham auricular acupuncture and control groups in the largest of the trials, which included 305 IVF patients (7Qu F. Zhang D. Chen L.T. Wang F.F. Pan J.X. Zhu Y.M. et al.Auricular acupressure reduces anxiety levels and improves outcomes of in vitro fertilization: a prospective, randomized and controlled study.Sci Rep. 2014; 4 (Level I): 5028PubMed Google Scholar). In another trial of 273 women treated with IVF-intracytoplasmic sperm injection (ICSI), the treatment group received acupuncture on the day of embryo transfer and had a clinical pregnancy rate of 39% compared with a control group that had no acupuncture 24% (P=.038) (9Westergaard L.G. Mao Q. Krogslund M. Sandrini S. Lenz S. Grinsted J. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial.Fertil Steril. 2006; 85 (Level I): 1341-1346Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). A meta-analysis of seven trials and 1,366 patients also showed an improved clinical pregnancy rate (odds ratio [OR] 1.65, 95% CI 1.27–2.14; seven trials) and live-birth rate (OR 1.91, CI 1.39–2.64; four trials) when acupuncture was given with embryo transfer (10Manheimer E. Zhang G. Udoff L. Haramati A. Langenberg P. Berman B.M. et al.Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis.BMJ. 2008; 336 (Level III): 545-549Crossref PubMed Scopus (0) Google Scholar). A systematic review did not show significant improvement in clinical pregnancy rate with acupuncture on the day of embryo transfer, 25 minutes before and after the transfer. It found a pooled benefit when performed 30 minutes after transfer and at implantation (RR 1.76, 95% CI 1.22–2.55; four trials) and also in the follicular phase and 25 minutes before and after transfer (RR 1.56, 95% CI 1.04–2.33; four trials) (11Shen C. Wu M. Shu D. Zhao X. Gao Y. The role of acupuncture in in vitro fertilization: a systematic review and meta-analysis.Gynecol Obstet Invest. 2015; 79 (Level III): 1-12Crossref PubMed Google Scholar). In addition, there was a 3-fold increased rate of pregnancy (95% CI 0.8, 8.0) and lower stress (not significant [NS]) associated with acupuncture in an observational cohort study of 57 women (12Balk J. Catov J. Horn B. Gecsi K. Wakim A. The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: a pilot study.Complement Ther Clin Pract. 2010; 16 (Level II-2): 154-157Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). While there were five RCTs that showed some benefit, seven RCTs showed no benefit to acupuncture (13Andersen D. Lossl K. Nyboe Andersen A. Furbringer J. Bach H. Simonsen J. et al.Acupuncture on the day of embryo transfer: a randomized controlled trial of 635 patients.Reprod Biomed Online. 2010; 21 (Level I): 366-372Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 14Craig L.B. Rubin L.E. Peck J.D. Anderson M. Marshall L.A. Soules M.R. Acupuncture performed before and after embryo transfer: a randomized controlled trial.J Reprod Med. 2014; 59 (Level I): 313-320PubMed Google Scholar, 15Madaschi C. Braga D.P. Figueira Rde C. Iaconelli Jr., A. Borges Jr., E. Effect of acupuncture on assisted reproduction treatment outcomes.Acupunct Med. 2010; 28 (Level I): 180-184Crossref PubMed Scopus (0) Google Scholar, 16Moy I. Milad M.P. Barnes R. Confino E. Kazer R.R. Zhang X. Randomized controlled trial: effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization.Fertil Steril. 2011; 95 (Level I): 583-587Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 17Smith C. Coyle M. Norman R.J. Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer.Fertil Steril. 2006; 85 (Level I): 1352-1358Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 18So E.W. Ng E.H. Wong Y.Y. Lau E.Y. Yeung W.S. Ho P.C. A randomized double blind comparison of real and placebo acupuncture in IVF treatment.Hum Reprod. 2009; 24 (Level I): 341-348Crossref PubMed Scopus (0) Google Scholar, 19So E.W. Ng E.H. Wong Y.Y. Yeung W.S. Ho P.C. Acupuncture for frozen-thawed embryo transfer cycles: a double-blind randomized controlled trial.Reprod Biomed Online. 2010; 20 (Level I): 814-821Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). In a trial of 416 women less than 36 years of age undergoing IVF with ICSI, the treatment group received acupuncture 25 minutes before and after embryo transfer with a pregnancy rate of 40.4% compared with the control group without acupuncture of 32.3% (P=.652) (15Madaschi C. Braga D.P. Figueira Rde C. Iaconelli Jr., A. Borges Jr., E. Effect of acupuncture on assisted reproduction treatment outcomes.Acupunct Med. 2010; 28 (Level I): 180-184Crossref PubMed Scopus (0) Google Scholar). Four meta-analyses similarly found no difference between acupuncture and control patients (11Shen C. Wu M. Shu D. Zhao X. Gao Y. The role of acupuncture in in vitro fertilization: a systematic review and meta-analysis.Gynecol Obstet Invest. 2015; 79 (Level III): 1-12Crossref PubMed Google Scholar, 20El-Toukhy T. Sunkara S.K. Khairy M. Dyer R. Khalaf Y. Coomarasamy A. A systematic review and meta-analysis of acupuncture in in vitro fertilization.BJOG. 2008; 115 (Level III): 1203-1213Crossref PubMed Scopus (0) Google Scholar, 21El-Toukhy T. Khalaf Y. The impact of acupuncture on assisted reproductive technology outcome.Curr Opin Obstet Gynecol. 2009; 21 (Level III): 240-246Crossref PubMed Scopus (0) Google Scholar, 22Manheimer E. van der Windt D. Cheng K. Stafford K. Liu J. Tierney J. et al.The effects of acupuncture on rates of clinical pregnancy among women undergoing in vitro fertilization: a systematic review and meta-analysis.Hum Reprod Update. 2013; 19 (Level III): 696-713Crossref PubMed Scopus (0) Google Scholar). In addition, a systematic review of eight studies (N=2,505) in which acupuncture was performed on or around the day of embryo transfer showed no evidence that acupuncture improved live-birth rate in ART (OR=1.22, 95% CI 0.87–1.70) (Fig. 1) (23Cheong Y.C. Dix S. Hung Yu Ng E. Ledger W.L. Farquhar C. Acupuncture and assisted reproductive technology.Cochrane Database Syst Rev. 2013; (Level III): Cd006920PubMed Google Scholar). Failure to demonstrate a difference in pregnancy rates with acupuncture could be a failure of the actual protocol tested rather than acupuncture itself. There may be some circumstances where pregnancy rates are improved with acupuncture, but there is no consistent evidence that live-birth rates are improved with acupuncture. Overall, the trials vary in design and have different findings, which make firm conclusions challenging.Summary statement:•There is fair evidence that acupuncture performed around the time of embryo transfer does not improve live-birth rates in IVF. (Grade B) Analgesics are occasionally recommended to help improve ART outcomes; however, there were no relevant studies identified through the literature search showing that the use of analgesics are associated with embryo transfer outcomes.Summary statement:•There is insufficient evidence to recommend for or against analgesics to improve IVF-embryo transfer outcomes. (Grade C) In an uncontrolled preliminary study, IVF outcomes were compared for patients who did or did not receive general anesthesia for embryo transfer. In this preliminary analysis, anesthesia showed benefit on the pregnancy rate in patients who received sodium thiopentone and alfentanyl (36%; n=86) vs matched controls who did not receive anesthesia (21%; n=131). However, when these investigators subsequently analyzed their data for two larger cohorts: one (n=603 embryo transfers) without anesthesia before the analysis, and a second group (n=795 embryo transfers) that received general anesthesia after the study, the pregnancy rate was 18% in the embryo transfers without anesthesia, and 19% in the embryo transfers with anesthesia. In this larger comparison, general anesthesia did not have a beneficial impact on pregnancy rate (24van der Ven H. Diedrich K. Al-Hasani S. Pless V. Krebs D. The effect of general anaesthesia on the success of embryo transfer following human in-vitro fertilization.Hum Reprod. 1988; 3 (Level II-2): 81-83Crossref PubMed Scopus (9) Google Scholar).Summary statement:•There is insufficient evidence that anesthesia during embryo transfer improves pregnancy rates. Given that there is no clear benefit and that there are inherent risks associated with anesthesia, routine anesthesia is not recommended to improve IVF-embryo transfer outcomes. (Grade C) Massage therapy is proposed as a way to relieve physical and psychological discomfort and has been suggested as a therapeutic modality without significant risk or side effects in an IVF cycle prior to embryo transfer. Only one study—a retrospective, observational analysis—assessed massage therapy before blastocyst transfer in cryopreservation cycles and demonstrated evidence of improved pregnancy and live-birth rates (25Okhowat J. Murtinger M. Schuff M. Wogatzky J. Spitzer D. Vanderzwalmen P. et al.Massage therapy improves in vitro fertilization outcome in patients undergoing blastocyst transfer in a cryo-cycle.Altern Ther Health Med. 2015; 21 (Level II-2): 16-22PubMed Google Scholar).Summary statement:•There is insufficient evidence to recommend for or against massage therapy to improve IVF-embryo transfer outcomes. (Grade C) One prospective, randomized trial on the effect of transcutaneous electrical acupoint stimulation (TEAS) on embryo transfer in 309 patients showed that electrodes placed on acupoints instead of needles improved the clinical pregnancy and live-birth rates relative to controls (26Zhang R. Feng X.J. Guan Q. Cui W. Zheng Y. Sun W. et al.Increase of success rate for women undergoing embryo transfer by transcutaneous electrical acupoint stimulation: a prospective randomized placebo-controlled study.Fertil Steril. 2011; 96 (Level I): 912-916Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). No statistically significant demographic differences were noted among the three groups (group I, mock TEAS; group II, single TEAS; group III, double TEAS; all treatments 30 minutes after embryo transfer). Also, the authors state that the number of transfers were not different among the three groups, but did not include these data in the manuscript. Clinical pregnancy and live-birth rates increased significantly in patients who received TEAS on the day of embryo transfer; the clinical pregnancy rate was 29.3% with mock TEAS vs 42.7% with single TEAS treatment (P=.044), and the live-birth rate was 21.2% with mock TEAS vs 37.3% with single TEAS treatment (P=.011). In patients who received TEAS also on the day before embryo transfer, the clinical pregnancy rate further increased to 50% (P=.003) and live-birth rate increased to 42% (P=.002) (26Zhang R. Feng X.J. Guan Q. Cui W. Zheng Y. Sun W. et al.Increase of success rate for women undergoing embryo transfer by transcutaneous electrical acupoint stimulation: a prospective randomized placebo-controlled study.Fertil Steril. 2011; 96 (Level I): 912-916Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). No additional studies of TEAS are available.Summary statement:•There is fair evidence based on only one RCT that TEAS improves IVF-embryo transfer outcomes. (Grade B). However, given the lack of any other studies, a recommendation for or against TEAS to improve IVF-ET outcomes cannot be made. Whole-systems traditional Chinese medicine (WS-TCM) as an approach to improve pregnancy rates in IVF can include acupuncture, Chinese herbal medications, diet, and lifestyle recommendations. Only one observational study of 119 non-donor and 21 donor patients was identified assessing WS-TCM and IVF-embryo transfer outcomes. This retrospective cohort study showed an improved live-birth rate of 61.3% with WS-TCM relative to 50.8% in the acupuncture group and 48.2% among controls in non-donor cycles (P=.03) (27Hullender Rubin L.E. Opsahl M.S. Wiemer K.E. Mist S.D. Caughey A.B. Impact of whole systems traditional Chinese medicine on in-vitro fertilization outcomes.Reprod Biomed Online. 2015; 30 (Level II-2): 602-612Abstract Full Text Full Text PDF PubMed Google Scholar). However, a number of limitations existed, including the retrospective nature of the study with lack of randomization, the fact that patients chose their treatment, and the lack of control of differing embryo quality between the groups.Summary statement:•There is insufficient evidence to recommend for or against WS-TCM to improve IVF-embryo transfer outcomes. (Grade C) Another intervention that has been considered to improve embryo transfer success rates is the use of prophylactic antibiotics. Only one RCT has addressed this issue (28Brook N. Khalaf Y. Coomarasamy A. Edgeworth J. Braude P. A randomized controlled trial of prophylactic antibiotics (co-amoxiclav) prior to embryo transfer.Hum Reprod. 2006; 21 (Level I): 2911-2915Crossref PubMed Scopus (0) Google Scholar). In that trial, 350 patients were randomized to receive either prophylactic antibiotics or no antibiotics. Those randomized to the treatment group received amoxicillin and clavulanic acid on the day before and the day of transfer. The catheter tips were cultured after the transfer. While the antibiotics significantly reduced catheter contamination rates, the clinical pregnancy rates between the two groups were not different. Live-birth rates were not an outcome of that trial. A systematic review of the literature in 2012 did not find any additional studies to help determine whether prophylactic antibiotics for embryo transfer were helpful, particularly for improving live-birth rates (29Kroon B. Hart R.J. Wong B.M. Ford E. Yazdani A. Antibiotics prior to embryo transfer in ART.Cochrane Database Syst Rev. 2012; (Level III): Cd008995PubMed Google Scholar). Their conclusion was that the finding of this single study did not support the use of amoxicillin and clavulanic acid to improve IVF success rates and that the effect of other regimens on IVF outcomes is unknown.Summary statement:•There is fair evidence based on a single RCT that an antibiotic regimen that includes amoxicillin and clavulanic acid given on the day before and the day of embryo transfer does not improve pregnancy rates. (Grade B). Given these results and the lack of other evidence in the literature to support prophylactic antibiotics at embryo transfer, a recommendation for routine prophylactic antibiotics cannot be made. Given that optimal handling of the embryo is imperative during embryo transfer, it is natural to consider the effect of the type of glove worn by the clinician performing the embryo transfer on outcome. There is no question that both powdered and unpowdered gloves are toxic when in direct contact with embryos. However, with the potential transmission of the powder from the gloves to the embryo transfer catheter through the air, particular concern has been raised regarding the use of powdered gloves during embryo transfer. Only one randomized controlled study addresses the impact of the type of glove utilized for embryo transfer on pregnancy rate. This study of 712 women evaluated the effect of powdered gloves on clinical pregnancy rate in IVF (37.6%) in comparison with unpowdered gloves (37.4%) and did not find a difference in pregnancy rate with the use of powdered gloves (P=1.0) (30Hannoun A. Zreik T.G. Ghaziri G. Abu Musa A. Awwad J. Effect of powdered gloves, worn at the time of embryo transfer, on the pregnancy outcome of IVF cycles.J Assist Reprod Genet. 2009; 26 (Level I): 25-27Crossref PubMed Scopus (0) Google Scholar). These investigators concluded that as long as direct contact is avoided, powdered gloves can safely be used in embryo transfer. There are no studies assessing glove use and live-birth rates. Therefore, although some physicians may opt to avoid non-sterile, latex, or powdered gloves in hopes of minimizing embryo toxicity, no data support the usage of a particular type of glove to optimize pregnancy rate.Summary statement:•There is fair evidence based on one, single-center RCT that powdered gloves worn during embryo transfer do not have an adverse effect on pregnancy rates. (Grade B). No specific type of glove is recommended for embryo transfer. There are 35 RCTs and cohort studies among other published data that examine the use of abdominal ultrasound guidance during embryo transfer. Ultrasound was introduced with the hope that it would diminish the likelihood that the embryo transfer catheter would traumatize the endometrium as compared with a blind approach or touch technique. With regard to the transfer of fresh embryos in eight RCTs and four cohort studies, transabdominal (TA) ultrasound—guided embryo transfer was found to improve the implantation rate and/or pregnancy rate (31Coroleu B. Carreras O. Veiga A. Martell A. Martinez F. Belil I. et al.Embryo transfer under ultrasound guidance improves pregnancy rates after in-vitro fertilization.Hum Reprod. 2000; 15 (Level I): 616-620Crossref PubMed Google Scholar, 32Coroleu B. Barri P.N. Carreras O. Martinez F. Veiga A. Balasch J. The usefulness of ultrasound guidance in frozen-thawed embryo transfer: a prospective randomized clinical trial.Hum Reprod. 2002; 17 (Level I): 2885-2890Crossref PubMed Google Scholar, 33Li R. Lu L. Hao G. Zhong K. Cai Z. Wang W. Abdominal ultrasound-guided embryo transfer improves clinical pregnancy rates after in vitro fertilization: experiences from 330 clinical investigations.J Assist Reprod Genet. 2005; 22 (Level I): 3-8Crossref PubMed Scopus (0) Google Scholar, 34Matorras R. Urquijo E. Mendoza R. Corcostegui B. Exposito A. Rodriguez-Escudero F.J. Ultrasound-guided embryo transfer improves pregnan" @default.
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• W2601095682 title "Performing the embryo transfer: a guideline" @default.
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