Association of Hyaluronic Acid-Enriched Transfer Medium (HETM) with Clinical Pregnancy Outcome in Women Undergoing Frozen-Thawed Embryo Transfer (FET).

In this present decade, assisted reproductive technologies have formed an important aspect of infertility treatments. To improve the success rate of in vitro fertilization/embryo transfer (ET) procedures, better pharmacological and surgical methods for ovarian stimulation, fertilization, embryo culture, and transfer have been developed. However, even with these progresses, it is still possible that a clinician may have difficulties when it comes to the implantation of the embryos.[ 1 ] Since invitro fertilization (IVF) ( in-vitro fertilization) was first introduced, scientists have known that adding proteins to culture media is essential for supporting embryo growth. Plasma proteins do a lot of important jobs—they help balance fluid levels, provide energy, and store and release.[ 2 ] while albumin is the most abundant macromolecule in the female reproductive system, glycosaminoglycans especially hyaluronan are also found in high concentrations.[ 3 ] One modification in ET media is the addition of hyaluronic acid (HA), also known as hyaluronic acid, which may enhance implantation. HA is a glycosaminoglycan naturally found in follicular, oviduct, and uterine fluids, and it’s thought to help with implantation by binding to CD44 glycoprotein receptors on the embryo, allowing HA to enter the cells. It also makes the transfer media thicker, which could help the embryo interact better with uterine fluid since their consistencies are more alike. Embryo Glue, an HA-enriched medium created by Vitro Life (Englewood, CO), is specifically designed to support embryos and improve implantation during ET. This study will explore how routinely using Embryo Glue impacts pregnancy rates (PR) and implantation rates (IR).[ 4 ] 52. Self-selection The study of females with recurrent implantation failure enrolled at Wardha Test Tube Baby Centre, Acharya vinoba Bhave rural hospital (AVBRH), Sawangi, Meghe, undergoing frozen-thawed embryo transfer (FET) cycles. Participants meet inclusion criteria to evaluate the impact of hyaluronic acid-enhanced transfer medium (HETM) on pregnancy outcomes. The study will include females aged 20–40 years who have a history of recurrent implantation failure is the inability to conceive following three or more prior [ Table 1 ] embryo transfers, and who are scheduled for FET cycles. Exclusion criteria will include women with significant comorbidities, such as severe endometriosis, uterine abnormalities, or uncontrolled thyroid disease, as well as those with contraindications to embryo transfer or those who have undergone oocyte or embryo donation cycles. After enrollment, Random assignment will be used to place individuals in either the experimental or control groups. Embryos in the experimental group will be cultured and transferred using a hyaluronic acid-enriched transfer medium (HETM) (e.g. Embryo Glue™) containing high-molecular-weight HA. The exposure time to HETM will be randomized into three subgroups: 10, 60, and 120 min. The control group will be treated with embryos transferred using conventional culture media without HA supplementation. All participants will be subjected to controlled ovarian stimulation. The controlled ovarian stimulation (COS) protocol will be individualized, based on characteristics such as age and response to other cycles, in addition to the ovarian reserve they possess. The ovarian stimulation protocol will either be long or short protocol, according to conventional practice. COS will be monitored by both serum estradiol and by ultrasound examination of follicular development. Inclusion and Exclusion Criteria The final maturation of the oocyte will be triggered by using either human chorionic gonadotropin (hCG) or a gonadotropin-releasing hormone (GnRH) agonist, according to the chosen ovarian stimulation protocol. Embryos are cultured in G1 or G2 culture media until the blastocyst stage, which is usually achieved on Day five or six. In the test group, the embryos are prepared and cultured using HETM, while those in the control group are prepared using conventional culture media. After evaluation by the embryologist regarding quality, top-quality blastocysts are chosen for transfer. Under the guidance of an ultrasound, the embryo transfer will be done on Day five or six after fertilization. A trained clinician who has experience handling embryo transfer cases will ensure the proper placement of the embryos into the uterine cavity. For participants in the experimental group, exposure to HETM will be strictly controlled according to the assigned exposure duration (10, 60, or 120 min). The primary outcome measures will include implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR). IR will be determined by the presence of a gestational sac on ultrasound 7–10 days after embryo transfer. CPR will be confirmed by serum hCG levels measured 10–14 days post-transfer and the presence of a fetal heartbeat on ultrasound 6–7 weeks post-transfer. LBR will be defined as the birth of a live infant at or beyond 20 weeks gestation. Secondary outcomes will include early pregnancy loss (EPL), defined as miscarriage before 12 weeks gestation; multiple birth rate (MBR), the number of participants delivering more than one live birth; and adverse pregnancy outcomes, including preterm birth and low birth weight. The study will be conducted at Wardha Test Tube Baby Center, JNMC, Sawangi, Maharashtra. HETM enhances embryo-endometrial interactions, potentially improving IRs and pregnancy success, especially in patients with implantation failure, though research results remain mixed. To Evaluate Patient Demographics: Assess the effectiveness of HETM across various demographic groups, including age, infertility diagnoses, and history of implantation failure to identify which subgroups benefit most from HA-enriched media. To Determine optimal exposure Duration: Investigate the effect of different incubation durations of embryos in HETM prior to transfer (e.g. comparing durations of 10 min, 60 min, and 120 min) on implantation and CPRs. To Analyze the interaction with ovarian Stimulation Protocols: Examine how various ovarian stimulation protocols (e.g. long vs. short Protocols) influence to outcome of FET using HETM, including implantation rates, clinical pregnancies, and adverse outcomes. To conduct comparative Effectiveness Research: Perform randomized controlled trials comparing HETM to conventional transfer media across different patient demographic and stimulation protocols to establish evidence the based practices for embryo transfer. To Assess Real—World clinical outcomes: Evaluate the real—World effectiveness of HETM in clinical settings, focusing on patient—reported outcomes, satisfaction, and overall treatment experiences. To Evaluate Patient Demographics: Assess the effectiveness of HETM across various demographic groups, including age, infertility diagnoses, and history of implantation failure to identify which subgroups benefit most from HA-enriched media. To Determine optimal exposure Duration: Investigate the effect of different incubation durations of embryos in HETM prior to transfer (e.g. comparing durations of 10 min, 60 min, and 120 min) on implantation and CPRs. To Analyze the interaction with ovarian Stimulation Protocols: Examine how various ovarian stimulation protocols (e.g. long vs. short Protocols) influence to outcome of FET using HETM, including implantation rates, clinical pregnancies, and adverse outcomes. To conduct comparative Effectiveness Research: Perform randomized controlled trials comparing HETM to conventional transfer media across different patient demographic and stimulation protocols to establish evidence the based practices for embryo transfer. To Assess Real—World clinical outcomes: Evaluate the real—World effectiveness of HETM in clinical settings, focusing on patient—reported outcomes, satisfaction, and overall treatment experiences. The hypothesis of this study posits that HETM will enhance implantation and CPRs in FET cycles, with variations in efficacy observed across different patient demographics, exposure durations, and ovarian stimulation protocols. It is anticipated that subgroups, particularly those with a history of repeated implantation failure, will experience the greatest benefit from HETM. Additionally, optimal durations of exposure to HETM are expected to yield improved clinical outcomes. Rates of IVF, clinical pregnancy, interpatient variability, duration of exposure, and the type of ovarian stimulation used. Formula for Sample Size per Group : Where: Step 1: Calculate Pooled Proportion Baseline pregnancy rate (p1p_1p1): 1% (0.01) Expected pregnancy rate with HETM (p2p_2p2): 10% (0.10) Significance level (α\alphaα): 5% (two-tailed) → Zα/2 = 1.96Z_{\alpha/2} =1.96Zα/2 = 1.96 Power: 50% → Zβ =0.00Z_{\beta} =0.00Zβ=0.00 (since ZβZ_{\beta} Zβ for 50% power is 0) Dropout rate: 5% Baseline pregnancy rate (p1p_1p1): 1% (0.01) Expected pregnancy rate with HETM (p2p_2p2): 10% (0.10) Significance level (α\alphaα): 5% (two-tailed) → Zα/2 = 1.96Z_{\alpha/2} =1.96Zα/2 = 1.96 Power: 50% → Zβ =0.00Z_{\beta} =0.00Zβ=0.00 (since ZβZ_{\beta} Zβ for 50% power is 0) Dropout rate: 5% Step 4: Simplify the Denominator Step 5: Calculate Raw Sample Size per Group Step 6: Adjust for Dropout Rate With a 5 % dropout rate: (p2 − p1) 2 = (0.10 − 0.01) 2 = 0.092 = 0.0081 Step 2: Plug Values into the Formula Step 3: Simplify the Numerator (1.96) 2 = 3.8416 p pooled . (1 - p pooled ) = 0.055 . 0.945 = 0.051975 Numerator = 3.8416.(0.051975.2) = 3.8416 = 0.3993 Per Group : 52 participants Total : 104 participants Per Group : 52 participants Total : 104 participants Participants will be randomized into either the experimental group receiving Hyaluronic Acid-Enriched Transfer Medium, HETM, or the control group with Standard Transfer Medium. In the experimental group, embryos will be cultured and transferred with HETM, whereas the control group will receive embryos transferred with conventional media. The randomization will also determine exposure durations of HETM, namely 10, 60, or 120 min, to assess optimal timing.

The purpose of the study is to evaluate the impact of hyaluronic acid-enriched transfer medium on pregnancy outcomes among women who have undergone frozen-thawed embryo transfer cycles. Results will focus on primary outcomes: implantation rate, CPR, and LBR as well as secondary outcomes like early pregnancy loss, multiple births, and adverse pregnancy events such as preterm birth and low birth weight. The study will also examine the effects of patient demographics, exposure duration (10, 60, and 120 min), and ovarian stimulation protocols on these outcomes. A total of 104 participants will be randomly allocated to either the experimental group-HETM or the control group-standard transfer medium.

Takuji Nishihara et al . (2017)[ 5 ] studied the effect of HA-enriched transfer media on FET outcomes. Low and high concentrations of HA were compared, including their effects on implantation, clinical pregnancy, and abortion rates. Sung Wook Chun et al . (2016)[ 6 ] conducted a study to assess the effectiveness of HA-rich transfer medium in improving implantation and PR in women of Korean origin who had a history of implantation failure after IVF. Studies prior to this showed promise but the results were not promising and no advantage over the standard media regarding implantation and PR was observed. The results align with other research indicating no substantial improvements with HA-enriched media. The authors noted factors like embryo quality, age, and endometrial conditions could overshadow HA’s potential benefits. Due to the study’s retrospective design and small sample size, the authors called for larger, prospective randomized controlled trials to better assess HA’s role in IVF and its potential integration into clinical practice. This study’s findings could provide valuable insights into the effectiveness of HETM in improving implantation and pregnancy outcomes in frozen-thawed embryo transfer cycles. Identifying optimal HA concentrations, exposure durations, and patient characteristics will help tailor ART protocols, potentially enhancing success rates in recurrent implantation failure case. Yes, ethical clearence issue from datta meghe institute. There are no conflicts of interest.