Tough Transfers

Sometimes you just want to pack it in and head for the islands... There is nothing quite as stressful as a tricky embryo transfer. Here you are in a darkened room with a patient who is not very comfortable as a result of having a full bladder and enlarged ovaries. There may be a concerned spouse/partner sitting at the head of the bed watching you like a hawk and the whole time you are trying to push a wet spaghetti noodle through a pinhole. Well maybe it is not that bad but it can be pretty frustrating.

Years ago in Long Island we did a study to determine if letting the catheter sit in the uterus for 2 minutes following the ET would increase pregnancy rates. I couldn't stand just sitting there watching the clock while 2 minutes ticked off the dial. So I hit upon the idea of playing a song that was about 2 minutes long. When the song ended I could just remove the catheter and we would be good to go. But what song would be appropriate for such a momentous interlude in a couple's life? Ultimately I chose Sam Cooke's hit song "You Send Me." I got so used to listening to the song that even after the study ended I continued to play it during all embryo transfers. It is now an inside joke at my clinic as all the patients remember that I play that song during all transfers. One patient snapped at her husband when he suggested a different song. Hey, if something works I stick with it!

So when an ET goes smoothly it looks like this:


But sometimes the ovaries are so large that the uterus gets pushed out of position, or the bladder isn't full or the picture isn't clear etc etc. Previously, we didn't use ultrasound for ET but this seems insane in retrospect. By filling the bladder, the position of the uterus improves and by visualizing the path of the catheter we can be sure that we are inside the uterus! Hard to get patients pregnant if you don't put the embryos in the right place!

If the transfer if nearly impossible then it is always the better part of valor to consider freezing the embryos and come back another day in another cycle to do the transfer. Once in a blue moon I will use IV sedation, as if for egg collection, in order to do the transfer. I am not a sadist and really want my patients to have a good experience and get pregnant along the way. If it is too tough then we bail out and reassess.

Many studies suggest that difficult transfers do not ultimately reduce pregnancy rates. That may be true but boy, it sure turns your hair gray and/or makes it fall out faster and I don't have that much hair to spare!

So if the transfer is not going well I will usually try the following:

1) Do a mock/trial transfer with an empty catheter
2) Fill/empty the bladder
3) Use a large q-tip to change the uterine angle
4) Pass a very small dilator through the cervix to map out the path
5) Try local analgesis / IV sedation
6) Freeze the embryos and try again in an FET cycle

Good luck to all of you and may all of your bladders be full, your transfers go easy and your embryos be above average! (with apologies to Garrison Keillor)