Hysteroscopic Embryo Implantation

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Hugo Verhoeven, MD: “Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Dusseldorf, and I’m on the Editorial Board of OBGYN.net. I am reporting today from the ASRM meeting in Seattle, and it’s a great pleasure for me talking this morning with Michael Kamrava, he is the Medical Director of the West Coast Infertility Medical Clinic in Beverly Hills, California. 

He told me before that he prefers to do a hysteroscopic embryo transfer because he was quite frustrated with all other techniques he used. Michael it is a pleasure for me talking to you. So maybe you will repeat to our listeners why you switched from the conventional embryo transfer methods to the hysteroscopic methods?”

Michael N. Kamrava, MD: “It’s my pleasure too, thank you. It was basically just as you said, our frustration with the blind embryo transfers because we can’t quite guide the blind, plastic tube inside the uterus. Also that scientifically the embryo when we put it in with a blind transfer it has a shell around it that doesn’t allow the embryos to stick to the lining of the uterus right away. And so there’s a real chance that that embryo can either get inside the fallopian tube, that’s why sometimes we have the tubal pregnancies from this procedure, or sometimes that embryo just falls out of the uterus, right after we put it in. 

I was thinking about it and in Mother Nature what happens is that that embryo hatches out of that shell by around day five or six and then it actually digs inside the lining of the uterus. That’s how it attaches to the uterus. So we thought, well why not mimic Mother Nature if we can to actually implant the embryo inside the lining and this way we will eliminate any chance that that embryo is going to move from the place that you put it. So we have eliminated tubal pregnancies and we have increased the pregnancy rates because there is much less chance of the embryo falling out of the uterus after you put it in.”

Hugo Verhoeven, MD: “So the important point is already that you’re doing a transferral blastocyst on day five, correct?”

Michael N. Kamrava, MD: “Yes, correct.”

Hugo Verhoeven, MD: “Okay. What instruments are you using?”

Michael N. Kamrava, MD: “The instrument is of two components: one is a combination of a rigid, flexible mini-hysteroscope and the other one is the transfer tubing that goes through the hysteroscope to deliver and implant the embryo inside the lining of the uterus.”

Hugo Verhoeven, MD: “What is the diameter of the device that you are entering into the cervical canal?”

Michael N. Kamrava, MD: “Roughly about three millimetres.”

Hugo Verhoeven, MD: “That’s quite, quite big?”

Michael N. Kamrava, MD: “Actually, right. For some patients that is a little bit big. That’s why we have to make some preparation for the patients and in all the patients, before we actually start the whole procedure, like at least a month or so before, and sometimes more if we have time, we actually dilate the cervix to make sure…”

Hugo Verhoeven, MD: “For hysteroscopy you dilate the cervix…yes, okay.”

Michael N. Kamrava, MD: “…hysteroscopic, right…procedure to make sure it stays open.”

Hugo Verhoeven, MD: “And as a distension medium you probably use CO₂?”

Michael N. Kamrava, MD: “We use a gas for the distension, right.”

Hugo Verhoeven, MD: “There’s no toxicity of the gas for the embryos?”

Michael N. Kamrava, MD: “For this one we actually use nitrous oxide for the distension instead of CO₂. It is an inert gas, that doesn’t affect the embryos.”

Hugo Verhoeven, MD: “Okay. So what are you doing exactly: you are bringing the hysteroscope and you told me before you’re imitating the implantation, so you do not do a transfer, you do an implantation of the embryo. What are you doing?”

Michael N. Kamrava, MD: “Right, exactly. What we do is introduce the hysteroscope, and as you introduce it inside the cervix you can actually see it on a screen. So you can actually guide the tip of the hysteroscope as you go in, so in difficult transfers it has helped actually quite a bit because you will minimise injury to the lining of the uterus as you introduce it because you can see it on the direct visualisation. 

Then, as you go in you can see the inside cavity of the uterus expand very nicely so there is very little chance of the instrumentation to damage the inside lining of the uterus because of the expansion and the narrow diameter of the hysteroscope. And then we go all the way up in the top of the uterus in the fundus and then the hysteroscope is already loaded with the embryo, and then we advance the tip of the catheter through the hysteroscope and then go just slightly inside the lining of the endometrium of the uterus and then release the embryo.”

Hugo Verhoeven, MD: “That means you’re really bringing the catheter into the endometrium?”

Michael N. Kamrava, MD: “Right, correct. It goes directly inside the endometrium."

Hugo Verhoeven, MD: “No bleeding?”

Michael N. Kamrava, MD: “There’s no bleeding. We’ve done over 150 patients so far, and there’s been no bleeding. There has been, initially in the first few patients, there was one patient who had a slight scratching of the lining of the uterus and we simply picked another place to implant the embryo and that patient did actually get pregnant. No problems.”

Hugo Verhoeven, MD: “Do we have an improved pregnancy rate using this technique?”

Michael N. Kamrava, MD: “We have looked at that, and in our own hands, in comparison with the blind procedure we have eliminated tubal pregnancies, that is zero ectopic pregnancies and the pregnancy rate by itself is about 70% higher than what we had with the blind procedure.”

Hugo Verhoeven, MD: “Seventy percent?”

Michael N. Kamrava, MD: “Seventy percent higher. Before we used to run on average, from all the patients, all ages and all different reasons for doing the in vitro, about 18% - 20% and right now we are running actually about 34% - 35%.”

Hugo Verhoeven, MD: “That’s quite interesting data. My final question is: you’re certainly trying to improve your technique and to find other possibilities to make the implantation rate higher – what are you thinking about?”

Michael N. Kamrava, MD: “I think you know at this point having come this far, I think this procedure now can be repeated in different hands to give similar results because it is not left to a chance. And I think the next step really in our attempts at improving the results would be to optimise the egg development and the quality of the eggs.”

Hugo Verhoeven, MD: “Well Michael, thank you very much for this very interesting interview. I wish you all the best, thank you very much.”

Michael N. Kamrava, MD: “Thank you and I appreciate it.”