Deep Dive

The IVF Transfer Checklist

Many patients think of the IVF transfer as an afterthought: compared to the hard work of making good embryos, placing embryos back in the uterus sounds pretty cut-and-dry. Really the opposite is true. Transferring embryos can be incredibly challenging and, in difficult cases, the success rates are far lower.

And as Scott Morin and Eric Forman from RMA New Jersey documented, even doctors hailing from the same clinic, and presumably meeting the same standards, have wildly different rates of transfer success.

So there is a spectrum of ability within the same clinic – that shouldn’t be a problem if clinicians are ready to ask for help (the whole point of a team, right)? But nearly 63% of fertility doctors say they never have, even with the truly hard cases.

When ASRM began poking around at how experienced clinicians really were, they found a few unnerving facts. First, the majority of residents performed less than 10 transfers before they graduated. And yes, 25% had never done a single transfer. Not good.

Second, you might assume that once newly-minted residents landed at a clinic, that clinic imposed strict standardization on how transfers would be done and temporarily recused doctors from doing transfers when their rates fell below some logical average. But you’d be wrong on both accounts: those practices are the exception, not the rule.

So when your transfer is approaching, or maybe well before, what measures can you take to make sure this final (but by no means trivial) step goes as well as humanly possible?

First, Think Hard About the Number of Embryos to Transfer


We cannot overstate the importance of thinking through the right number of embryos to transfer. As we’ve chronicled, the number of embryos you choose to transfer has enormous medical consequences and as we’ve also pointed out, most patients just go along with the wishes of their doctor.

Below is the new upper-limit recommendation from ASRM. If your doctor is prepared to go higher, you should see this as a warning sign and wonder what other data-driven conventions they’re comfortable ignoring.

*“Other favorable” includes any of the following: Fresh Cycle – expectation of 1 or more high-quality embryos available for cryopreservation, or previous live birth after an IVF cycle. Frozen Cycle – availability of vitrified day-5 or day-6 blastocysts, euploid embryos, 1st frozen frozen transfer or previous live birth after an IVF cycle

Second, Figure Out Who Is Transferring


You have a right to know who will be transferring your embryos and what their success rates are. 94% of clinics say they “keep track of each practitioner’s embryo transfer success rate” and most update this at least twice per year. Preferably you’d want to get this information as early as possible to either make a request, or in situations where you feel uncomfortable whom you might get, think of alternatives. We should tell you, your asking will be new for many clinics. But they should have the data and it should matter to you.

Third, Understand Whether Your Doctor Will Follow Protocols


The ASRM has reviewed the literature and determined there is a clear list of measures that lead to better outcomes. You may want to make sure whomever is doing your transfer plans to follow best practices.

  • Abdominal ultrasound for embryo transfer (93% of clinics say they comply)

  • Removal of cervical mucus (74% of clinics say they comply)

  • Use of a soft embryo transfer catheter

  • Placement of embryo transfer tip in the upper or middle (central) area of the uterine cavity, greater than 1 cm from the fundus, for embryo expulsion (80 – 90% of clinics say they comply

  • Immediate ambulation once transfer is completed, so essentially, no bedrest (30% of clinics say they comply). And since most patients ask, here is one of many studies on the subject.

Similarly, there are commonly-performed interventions the fertility community is not yet prepared to declare effective. If you don’t want to do any of these, you have plenty of data on your side.

  • Acupuncture (there is disagreement, see here), whole systems –traditional Chinese medicine or massage around transfer time

  • Use of analgesics

  • General anesthesia during transfer (and in light of the risks of anesthesia, it is explicitly not recommended if the goal is to improve outcomes)

  • Prophylactic antibiotics to improve embryo transfer