BACKGROUND Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists. OBJECTIVE AND RATIONALE We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes. SEARCH METHODS We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses. OUTCOMES Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs. WIDER IMPLICATIONS Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.

中文翻译：

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优化接受辅助受孕妇女胚胎移植的干预措施：综合系统评价和荟萃分析。

背景 建议采用几种干预措施和技术来改善辅助受孕中胚胎移植 (ET) 的结果。然而，对于最佳实践仍未达成共识，生育专家之间存在很大差异。目标和基本原理 我们对随机对照试验 (RCT) 进行了全面的系统回顾和荟萃分析，旨在确定可以在 ET 期间引入的有效干预措施，以改善生殖结果。搜索方法 我们使用 MeSH 术语和关键字的多阶段搜索策略搜索了从开始到 2021 年 3 月的电子数据库（MEDLINE、EMBASE 和 Cochrane CENTRAL），并包括所有评估干预前后 24 小时内干预的随机对照试验接受 IVF/ICSI 的女性的 ET。我们的主要结果是经超声扫描确认为可行妊娠的 ET 后临床妊娠率。我们评估了纳入试验的偏倚风险并一式两份提取数据。我们使用随机效应荟萃分析汇总数据，并使用风险比 (RR) 和 95% CI 进行报告。我们使用亚组分析探索了发表偏倚和效应修饰符。结果 我们的搜索产生了 3685 次引用，其中我们纳入了 188 项随机对照试验（38 项干预措施，59530 名参与者），中位样本量为 200（范围 26-1761）。纳入的 RCT 质量中等，大多数显示随机化 (118/188, 62.8%) 和损耗 (105/188, 55.8%) 的低偏倚风险，但存在显着的发表偏倚风险（Egger 检验 P = 0.001 ). 使用超声引导与临床接触进行 ET（n = 24，RR 1.265，95% CI 1.151-1.391，I2 = 38.53%)、透明质酸与常规护理（n = 9，RR 1.457，95% CI 1.197-1.261，I2 = 46.48%）和使用软导管与硬导管（n = 27，RR 1.122，95%） CI 1.028-1.224，I2 = 57.66%）导致更高的临床妊娠率。其他药物添加物也显示出有益效果，包括粒细胞集落刺激因子（G-CSF：n = 4，RR 1.774，95% CI 1.252-2.512，I2 = 0），阿托西班（n = 7，RR 1.493，95 % CI 1.184-1.882，I2 = 68.27%）和 hCG（n = 17，RR 1.232，95% CI 1.099-1.382，I2 = 57.76%）。ET 后卧床休息与临床妊娠率降低相关（n = 6，RR 0.857，95% CI 0.741-0.991，I2 = 0.01%）。其他常用的干预措施，如非甾体抗炎药、预防性抗生素、针灸和宫颈粘液清除，并未显示出对生殖结果的显着益处。我们对其他重要结果（包括流产和活产）的影响估计受到纳入 RCT 的不同报告的限制。更广泛的意义 在 ET 时使用超声引导、软导管和透明质酸似乎可以提高临床妊娠率。阿托西班、G-CSF 和 hCG 的使用显示出增加临床妊娠率的趋势，但在临床实践中采用这些干预措施之前需要进行更大规模的试验。ET 后卧床休息与临床妊娠率降低相关，因此不应推荐。ET 时的软导管和透明质酸似乎可以提高临床妊娠率。阿托西班、G-CSF 和 hCG 的使用显示出增加临床妊娠率的趋势，但在临床实践中采用这些干预措施之前需要进行更大规模的试验。ET 后卧床休息与临床妊娠率降低相关，因此不应推荐。ET 时的软导管和透明质酸似乎可以提高临床妊娠率。阿托西班、G-CSF 和 hCG 的使用显示出增加临床妊娠率的趋势，但在临床实践中采用这些干预措施之前需要进行更大规模的试验。ET 后卧床休息与临床妊娠率降低相关，因此不应推荐。