FROZEN REPLACEMENT CYCLE

DR ARUN RAY CHAUDHURI

Email: arun_ray04@rediffmail.com
• Frozen Embryo Replacement protocol:
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• Natural FER cycle: In natural FER cycle transfer is usually timed
using a combination of usg monitoring to confirm follicular
development and urinary or serum detection of LH surge.
• The major advantage to replacement in a natural cycle is that no
medication is required and the time taken to complete the cycle is
short. However there will be a significant proportion of women for
whom this approach is not suitable such as women with
anovulatory polycystic ovary syndrome.
• Some clinics advocate the use of human chorionic gonadotropin to
trigger ovulation and to aid in the timing of embryo replacement.
• Use of hCG trigger compared to ultrasound and LH monitoring
decreased the number of monitoring visits required with no
difference in pregnancy rate.
• However if urinary LH tesing is undertaken, multiple visits for
usg monitoring should be unnecessary.
• The question of luteal phase progesterone supplementation in
natural cycle FER has been addressed in two RCTs, with mixed
results. One study found a significant increase in LBR though not
CPR, in women receiving vaginal progesterone. However a
further RCT , using hCG as trigger, found no improvement in CPR
when luteal I.M progesterone was given.
•  
• Hormone-replacement cycles:
• One benefit of medicated FER cycles may be increased flexibility as to the
timing of embryo transfer that may suit both the patient and the clinic
[ e.g.,the avoidance of week end thawing and transfer ]
• A number of different protocols exist. First, ovarian down regulation can be
achieved by the use of a gonadotropin –releasing hormone [ GnRH] agonist
for two to three weeks, after which estrogen and then progesterone is used.
A simpler regime commencing estrogen on day 2 of the cycle [ which
prevents follicular recruitment ] with the addition of progesterone later,
with or without the use of a GnRH antagonist, is also commonly followed.
• There is no difference in pregnancy rate, cycle cancellation,endometrial
thickness or miscarriage rates between GnRh analogue followed by
hormone replacement or hormone replacement only.
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• ENDOMETRIAL THICKNESS AND QUALITY IN FER CYCLES  
• Implantation and pregnancy rates were significantly lower when the
endometrial thickness was less than 7 mm and more than 14 mm.
Although in fresh IVF cycles a triple line is associated with an
increased clinical pregnancy rates, in FER cycles no such association
has been identified. However a non homogeneous hyperechogenic
endometrial echo 3 days after FER was shown to be associated with
reduced pregnancy rate. A decreased mean uterine artery PI value
improves conception in FER cycle.
• Presence of subendometrial–endometrial blood flow on 2D power
doppler is associated with significant improvement in implantation.
• ZONA PELLUCIDA BREACHING BEFORE FER
• It is thought that the process of cryopreservation
may cause hardening of the zona pellucida and
therefore assisted hatching may be beneficial in FER
cycles.
• However evidence suggest in eight RCT , no
difference in CPR with the use of assisted hatching.
• SAFETY OF CHILDREN BORN AFTER FER CYCLES
• The safety of embryo cryopreservation has been questioned.
• Concerns have been raised regarding its effects on embryonic
gene expression and metabolism, as well as the potential
negative effects of cryoprotectants. However studies found no
difference in the physical outcomes at three years of age
between children born from fresh compared to frozen cycles. In
addition , no difference in obstetric outcome or congenital
malformation has been found, rather it has actually found better
obetetric and perinatal outcome and found increased large for
gestational age ,macrosomic singleton birth after FER cycles.
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THANK YOU