Is embryo transfer procedure painful?

In normal conditions, it shouldn’t be painful at all. When patients ask me about how the transfer is, usually, I tell them that it’s going to be like having a normal pap smear, and therefore, the only thing that can be uncomfortable is the use of the speculum because we need to see the cervix.

The first thing that you need to do is to decide the size of the speculum based on each patient. We can work with the vaginal speculum that is really thin and very comfortable. In some cases, we may need longer or thicker speculum to get a perfect view of the cervix.

The catheter is thin, it’s like half a millimetre, and we are placing it inside. Unless there is something wrong with the cervix, either because the patient has had surgery or there has been some kind of abnormality or disease, etc., it should be very easy. When we are using the ultrasound,  the nurse guides the doctor, and we know exactly how we have to proceed to get into the cervix. Sometimes, there is indeed a cervix that looks like rollercoasters because you have to go first down, then up, and it could be really tricky to get into that.  There are different things that you can do to try to make it easier like working with a full bladder because if you have a full bladder, it is going to push the uterus back. Sometimes, in cases especially in which there is a  really difficult angle between the cervix and the body. If you push the body back, the angle is going to be much easier, and the transfer as well.

Knowing your patient and making the decisions before the transfer should make it easy and absolutely painless in the majority of the cases.

The procedure is actually not more than a little bit of discomfort, like with a smear test. That’s in general terms. So if you can tolerate well the smear test, you should be able to tolerate well the embryo transfer. Because it’s exactly the same procedure: we insert the speculum, we identify the cervix and then we perform the transfer through a very small tiny catheter. However, the pain or the discomfort is mainly from the bladder that is getting full. As you know, nowadays we are performing the transfer under ultrasound guidance – and for the ultrasound guidance, we need a full bladder in order to see clearly the procedure of the embryo transfer and where exactly we are putting the embryo. So if someone needs a very full bladder, that’s one thing that could make you have this kind of discomfort. And they feel it even more after the embryo transfer because they cannot go to the toilet straight away. They are asked to remain in bed or on the couch for another 20 minutes or half an hour. I think this is the time when patients feel that they are really bursting. So if you can avoid having like over-full bladder, that’s one thing that can help to avoid the discomfort. Having any sort of analgesia before the embryo transfer is not recommended – it’s not the procedure that needs that kind of analgesia, like egg collection.

In the era before having the embryo transfer under ultrasound guidance, we used to do it blindly. So it was more painful at that time because we didn’t know exactly where to go and how to guide ourselves. It was a very crude way of assessing the cervical canal. However, now with the introduction of ultrasound guidance, it is making the procedure better and smooth. Why? Because it goes with the catheter following exactly the track of the cervical canal, reaching the uterine cavity and depositing the embryo exactly where it should be, just under the fundus by 1-1,5 cm. I do this technique with other procedures. You may think about it as the way to see exactly where we are going: it avoids all this kind of pain that you could feel through false passages or going the wrong way if the uterus is in a particular position. However, let me assure you that this is now reduced to a minimum because of the use of ultrasound guidance. I have asked many patients and we have set the pain score of patients as feedback: they mainly commented that the pain was due to a full bladder and the period of resting after the actual procedure. Hence, we have started to think about having the embryo transfer under the transvaginal ultrasound scan. So it does not require a full bladder and it’s a clearer view. However, it has to have a little bit of modification of the technique. Not every clinic and every doctor is happy to perform it under this procedure. However, if we can try to avoid it, I think in the future this is the way forward.

Unlike the oocyte pickup, the embryo transfer is actually much easier and in a vast majority of the cases it can be hardly felt so it’s completely pain free. There might be some exceptions – especially if the uterus is sharply bent forward or backwards but we try to follow this during the preparation and the IVF process itself with the ultrasound checks. There are various techniques which we can use to actually access the uterine cavity without any pain for the patient. So usually the embryo transfer you don’t need to worry about – it’s hardly felt at all.

Usually not and it shouldn’t be unless of course the patient has some more underlying issues that can make it challenging. Usually in 99% of the cases, the embryo transfer is not painful. It’s just like a smear test – there shouldn’t be any gross discomfort. In cases whereby the uterus is either retroverted or anteverted which means that the uterus is standing up or really facing down, putting the catheter can be a bit challenging and can be a bit uncomfortable, so in those odd cases, it can be a bit painful just getting the catheter in but usually, as I said, in 99% of the cases it’s very straightforward.

It is very important to do embryo transfer without pain. Because if it is painful, it can cause some slight contractions of the uterus. It lowers the chances of implantation. But it’s very individual. Some women are more sensitive, some women are less sensitive. It also depends on anatomic conditions. If for example, the uterus is strongly curved, it’s impossible to do it painlessly. Fortunately, approx. 90% of transfers are painless, and only 10% of transfers are a bit painful. It is very individual but it is best when it is quick and painless.

Sometimes after embryo transfer, you can feel some pain or pressure similar to the one before period or during the period – it’s quite common. Sometimes, I recommend taking painkillers after transfer if the pain is strong. They are not dangerous. But as I said it’s not a bad sign, and it’s common.

Normally, embryo transfer is a process of 1-2 minutes, very easy and quick. But, if the patient has had previous surgery on the cervix, infections, abortion, it can cause some changes in the outside and the inside of the uterus. There can be some distortions, and it can cause a difficult transfer. But with an experienced gynecologist and a well-chosen catheter, we can finish embryo transfer, even those difficult ones in 5-10 minutes. Also, a good ultrasonographer can make our work easy on the gynecologist’s side because if you can see on the ultrasound where to pass, how to change the way, the transfer gets easier.

In the past, when we started doing embryo transfers, we had to grasp the cervix, do some traction, and it could cause some pain or contractions. In this case, the success rate was lower, the process was longer, and there was some pain. The contractions can be felt by patients like pelvic pain. This is like dysmenorrhea, the menstrual pain. If you feel something like this, there are some special suppositories to relax the uterus. Here, after any kind of embryo transfer, easy or difficult, we always give the patient a rectal suppository to relax the uterus. We believe that it can raise our chances to succeed. Now, embryo transfers are very quick, easy, and without pain.

The majority of the embryo transfers should be really completely painless. Patients shouldn’t feel anything, except, obviously, the discomfort related to the speculum, the instrument that we insert at the beginning to expose the neck of the womb. But the moment we pass the catheter in and release the embryo should be completely painless. It’s not always straightforward to cannulate the neck of the womb and insert the embryo inside. Sometimes, we have to use some instruments which can actually be painful for the patient. But normally, we tend to do that with some painkillers or sedation. And so that obviously helps the patients not to feel any pain.

That’s one side of the story. In my experience, what happens sometimes is that in patients who have never had any deliveries or have never been pregnant, their neck of the womb can be a little bit stiff and closed. Sometimes, when the catheter goes past the inside of the neck of the womb, it is called internal opening or internal loss. The patients might feel like an electric shock, something like that. It feels like that. It has been described to me like that. That is a good sign in a way because that means that the catheter is inside and in the right place. But it is a bad sign in the sense that the “electric shock” feeling means that there have been some contractions triggered in the womb. When you trigger contractions, the muscles of the womb are actually too active. Those contractions, if you transfer the embryo, may push the embryo out straight away.

So it is very important when the patient feels the pain to stop the procedure leaving the catheter still in, but just take a little bit of time. Wait until those contractions or this kind of period pain or “electric shock” whatever it is called settle, and then transfer the embryo only when the pain is gone.

Generally, there shouldn’t be any pain. It should be totally painless. The ultrasound helps in visualizing that you are in the right place. However, it’s not very easy to visualize the uterus’ contractions using ultrasound. It can be done, but not all machines have this level of precision. There have been lots of studies, in fact,  there is one on the topic which has been very interestingly researched recently. And to look at the waves of the contractions during embryo transfer. Because he has been a few papers recording that the uterus contracts during embryo transfer. Of course, it reacts to a foreign body which is the catheter. So that sometimes translates into feeling pain or feeling discomfort. As I said, it would be good to let those contractions settle and then proceed with the transfer of the embryo.

The embryo transfer procedure requires a speculum to be placed into the vagina so that the catheter containing the embryo can be passed through the neck of the womb. It isn’t recommended to use any lubricants in case they affect the embryo, and with a full bladder the procedure may be uncomfortable, but it should not be painful. If you are experiencing pain during the embryo transfer, let one of the members of your team know.