Cleavage stage versus blastocyst stage embryo transfer in assisted conception

Debbie A Blake; Michelle Proctor; Neil Johnson; David Olive; Cindy M Farquhar; Quirine Lamberts

doi:10.1002/14651858.CD002118.pub2

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Analysis 1.1

Comparison 1 Live birth rate, Outcome 1 Live birth per couple.

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Analysis 1.2

Comparison 1 Live birth rate, Outcome 2 Live birth per couple: grouped by number of embryos transfer.

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Analysis 1.3

Comparison 1 Live birth rate, Outcome 3 Live birth rate per couple: group by prognosis.

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Analysis 1.4

Comparison 1 Live birth rate, Outcome 4 Live birth rate: grouped by day of randomisation.

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Analysis 1.5

Comparison 1 Live birth rate, Outcome 5 Live birth per OPU.

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Analysis 1.6

Comparison 1 Live birth rate, Outcome 6 Live birth per OPU: grouped by numbers of embryos transferred.

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Analysis 1.7

Comparison 1 Live birth rate, Outcome 7 Live birth rate per OPU: grouped by prognosis.

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Analysis 1.8

Comparison 1 Live birth rate, Outcome 8 Live birth rate per ET.

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Analysis 1.9

Comparison 1 Live birth rate, Outcome 9 Live birth per ET: grouped by number of embryos transferred.

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Analysis 1.10

Comparison 1 Live birth rate, Outcome 10 Live birth per ET: grouped by prognosis.

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Analysis 2.1

Comparison 2 Clinical pregnancy rate, Outcome 1 Clinical pregnancy rate per couple.

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Analysis 2.2

Comparison 2 Clinical pregnancy rate, Outcome 2 Clinical pregnancy rate per couple: grouped by number of embryos transferred.

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Analysis 2.3

Comparison 2 Clinical pregnancy rate, Outcome 3 Clinical pregnancy rate per couple: grouped by prognosis.

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Analysis 2.4

Comparison 2 Clinical pregnancy rate, Outcome 4 Clinical pregnancy rate per couple: grouped by day of randomisation.

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Analysis 2.5

Comparison 2 Clinical pregnancy rate, Outcome 5 Clinical pregnancy rate per OPU.

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Analysis 2.6

Comparison 2 Clinical pregnancy rate, Outcome 6 Clinical pregnancy rate per OPU: grouped by number of embryos transferred.

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Analysis 2.7

Comparison 2 Clinical pregnancy rate, Outcome 7 Clinical pregnancy rate per OPU: grouped by prognosis.

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Analysis 2.8

Comparison 2 Clinical pregnancy rate, Outcome 8 Clinical pregnancy rate per ET.

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Analysis 2.10

Comparison 2 Clinical pregnancy rate, Outcome 10 Clinical pregnancy rate per ET: grouped by prognosis.

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Analysis 2.11

Comparison 2 Clinical pregnancy rate, Outcome 11 Clinical pregnancy rate per ET: grouped by number of embryos transferred.

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Analysis 3.1

Comparison 3 Multiple‐pregnancy rate, Outcome 1 Multiple‐pregnancy rate per couple.

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Analysis 3.2

Comparison 3 Multiple‐pregnancy rate, Outcome 2 Multiple‐pregnancy rate per couple: grouped by number of embryo transfer.

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Analysis 3.3

Comparison 3 Multiple‐pregnancy rate, Outcome 3 Multiple‐pregnancy rate per couple: grouped by prognosis.

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Analysis 3.4

Comparison 3 Multiple‐pregnancy rate, Outcome 4 High order pregnancies (more than 2 gestational sacs) per couple.

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Analysis 3.5

Comparison 3 Multiple‐pregnancy rate, Outcome 5 High order pregnancy: grouped by number of embryos transferred.

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Analysis 3.6

Comparison 3 Multiple‐pregnancy rate, Outcome 6 High order pregnancies: grouped by prognosis.

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Analysis 3.7

Comparison 3 Multiple‐pregnancy rate, Outcome 7 Multiple‐pregnancy rate per pregnancy.

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Analysis 3.8

Comparison 3 Multiple‐pregnancy rate, Outcome 8 High order pregnancies per total pregnancies.

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Analysis 3.9

Comparison 3 Multiple‐pregnancy rate, Outcome 9 Multiple‐pregnancy rate per pregnancy: grouped by number of embryos transferred.

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Analysis 4.1

Comparison 4 Miscarriage rate, Outcome 1 Miscarriage rate per couple.

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Analysis 4.2

Comparison 4 Miscarriage rate, Outcome 2 Miscarriage rate per pregnancy.

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Analysis 5.1

Comparison 5 Embryo freezing rate, Outcome 1 Embryo freezing per couple.

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Analysis 5.2

Comparison 5 Embryo freezing rate, Outcome 2 Embyro freezing per couple: grouped by number of embryos transferred.

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Analysis 5.3

Comparison 5 Embryo freezing rate, Outcome 3 Embryo freezing per couple: grouped by prognostic factors.

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Analysis 6.1

Comparison 6 Failure to transfer embryos rate per couple, Outcome 1 Failure to transfer any embryos per couple.

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Analysis 6.2

Comparison 6 Failure to transfer embryos rate per couple, Outcome 2 Failure to transfer any embryos per couple: grouped by number of embryos transferred.

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Analysis 6.3

Comparison 6 Failure to transfer embryos rate per couple, Outcome 3 Failure to transfer any embryos per couple: grouped by prognostic factors.

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Analysis 7.1

Comparison 7 Cumulative pregnancy rate, Outcome 1 Cumulative pregnancy rate from fresh and frozen transfers.

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Table 1. Culture Techniques of Included Studies

Trial	Culture Tech Day 2/3	Culture Tech Day 5/6
Bungum 2003	Sequential G1 VItrolife	Sequential G1/G2 Vitrolife
Coskun 2000	Sequential Medicult	Sequential G1/G2 Vitrolife
Devreker 2000	NS	NS
Emiliani 2003	In‐house sequential (based on G1/G2)	In‐house sequential (based on G1/G2)
Frattarelli 2003	Sequential NS	Sequential NS
Gardner 1998a	Single Hams F10 In‐house	Sequential G1/G2 In‐house
Hreinsson 2004	Vitro life IVF	Squential G1/G2 or CCM Vitrolife
Karaki 2002	Medicult	Sequential G1/G2 Vitrolife
Kolibianakis 2004	Sequential G1 Vitrolife	Sequential G1/G2 Vitrolife
Levitas 2004	NS	Sequential ‐ G1/G2 Vitrolife
Levron 2002	NS	NS
Livingstone 2002	Sequential ‐ Sydney IVF Cook	Sequential ‐ Sydney IVF Cook
Motta 1998	Sequential ‐ Irvines P1	Sequential ‐ Irvines P1 then Blast media
Rienzi 2002	Sequential G1 Vitrolife	Sequential G1/G2 Vitrolife
Schillaci 2002	NS	NS
Van der Auwera 2002	Sequential both Cook and Vitrolife	Sequential both Cook and Vitrolife

Table 1. Culture Techniques of Included Studies

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Table 2. Study Quality


Study ID	Grade for concealment of allocation	Method of concealment of allocation	Randomisation procedure	ITT	Similar number of embryos transferred	Prognostic factors of patients/cycles	Day of randomisation	Notes
Bungum 2003	A	Sealed envelope	Unknown	Yes, no dropouts or exclusions	Yes	Good	Day 3 post ovum pick up
Coskun 2000	A	Sealed envelope	Unknown	Yes, no dropouts or exclusions	Yes	Good	Day of ovum pick up
Devreker 2000	B	Unknown	Unknown	Yes, no dropouts or exclusions	No	Poor	Not stated
Emiliani 2003	B	Unknown	Randomisation list	10 women were subsequently excluded for protocol violations	Yes	Unselected	Start of cycle
Frattarelli 2003	A	Yes but not clear how this was achieved	Computer generated	Yes, 8 women withdrawn for when embryos did not meet criteria were added to the denominator and analysed	No	Good	Day of ovum pick up (Day 1)
Gardner 1998a	B	Unknown	Computer generated	Yes, no dropouts or exclusions	No	Good	8 days prior to ovum pick up but final decision about inclusion on day of trigger
Hreinsson 2004	B	Sealed envelope	Unknown	Yes no drop outs or exclusions	Yes	Good ‐ no poor	1 day prior to HCG
Karaki 2002	A	Sealed envelope	Unknown	Yes, no dropouts or exclusions	No	Unselected	Day 1 fertilisation
Kolibianakis 2004	C	None	Computer generated	Yes, no dropouts or exclusions	Yes	Unselected	Prior to stimulation
Levitas 2004	A	Sealed envelope	Computer generated	Yes, no dropouts or exclusions	No	Poor	Prior to stimulation
Levron 2002	A	Sealed envelope	Unknown	Yes, no dropouts or exclusions	No	Good	Day of ovum pick up (Day 1)
Livingstone 2002	A	Sealed envelope	Computer generated	20 women excluded post randomization as they did not have a transfer, not sure which group	No	Good	Prior to ovum pick up
Motta 1998 A&B	B	Unknown	Unknown	Yes, no dropouts or exclusions	No	Unselected	Not stated
Rienzi 2002	B	Unknown	Computer generated	Yes, no dropouts or exclusions	Yes	Good	Day of ovum pick up (Day 1)
Schillaci 2002	B	Unknown	Unknown	Yes, no dropouts or exclusions	No	Unselected	Day 1 fertilisation check
Van der Auwera 2002	A	Sealed envelope	Unknown	Yes, 7 dropouts after randomisation (3 from day 2, 4 from Day 5) were added to the denominator and analysed.	Yes	Unselected	Start of cycle

Table 2. Study Quality

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Comparison 1. Live birth rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Live birth per couple Show forest plot	7	629	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.74, 1.44]

2 Live birth per couple: grouped by number of embryos transfer Show forest plot	7	629	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.03 [0.74, 1.44]

2.1 Equal number of embryos transferred	3	405	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.00 [0.67, 1.49]
2.2 More cleavage stage than blastocyst embyros transferred	4	224	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.11 [0.60, 2.07]
3 Live birth rate per couple: group by prognosis Show forest plot	7	629	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.74, 1.44]

3.1 Good prognostic factors	3	245	Odds Ratio (M‐H, Fixed, 95% CI)	0.94 [0.56, 1.57]
3.2 Poor prognostic factors	2	77	Odds Ratio (M‐H, Fixed, 95% CI)	2.05 [0.53, 7.96]
3.3 Unselected group	2	307	Odds Ratio (M‐H, Fixed, 95% CI)	1.02 [0.64, 1.63]
4 Live birth rate: grouped by day of randomisation Show forest plot	7	629	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.74, 1.44]

4.1 Randomisation at start of cycle	3	361	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.67, 1.64]
4.2 Randomised on day of OPU and day 1 after OPU	3	245	Odds Ratio (M‐H, Fixed, 95% CI)	0.94 [0.56, 1.57]
4.3 Randomised Day 2 to 3 post OPU	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 Day of randomisation unstated	1	23	Odds Ratio (M‐H, Fixed, 95% CI)	4.13 [0.36, 47.30]
5 Live birth per OPU Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Live birth per OPU: grouped by numbers of embryos transferred Show forest plot	7		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 Equal number of embryos transferred	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 More cleavage stage than blastocyst embryos transferred	5		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Live birth rate per OPU: grouped by prognosis Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Good prognosis	3		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Poor prognosis	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Unselected	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Live birth rate per ET Show forest plot	8		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9 Live birth per ET: grouped by number of embryos transferred Show forest plot	8		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.1 Equal number of embryos transferred	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 More cleavage stage than blastocyst embryos transferred	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Live birth per ET: grouped by prognosis Show forest plot	8		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.1 Good prognosis	4		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Poor prognosis	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 Unselected	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Live birth rate

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Comparison 2. Clinical pregnancy rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Clinical pregnancy rate per couple Show forest plot	15	2042	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.88, 1.26]

2 Clinical pregnancy rate per couple: grouped by number of embryos transferred Show forest plot	15	2042	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.88, 1.26]

2.1 equal numbers of ET	6	1157	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.83, 1.34]
2.2 more cleavage stage than blastocyst embryos transfered	9	885	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.80, 1.38]
3 Clinical pregnancy rate per couple: grouped by prognosis Show forest plot	15	2042	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.88, 1.26]

3.1 Good prognostic factors	7	800	Odds Ratio (M‐H, Fixed, 95% CI)	0.94 [0.71, 1.25]
3.2 Poor prognostic factors	2	77	Odds Ratio (M‐H, Fixed, 95% CI)	2.69 [0.81, 8.96]
3.3 Unselected group	6	1165	Odds Ratio (M‐H, Fixed, 95% CI)	1.10 [0.86, 1.39]
4 Clinical pregnancy rate per couple: grouped by day of randomisation Show forest plot	15	2042	Odds Ratio (M‐H, Fixed, 95% CI)	1.05 [0.88, 1.26]

4.1 Randomised start of cycle	5	913	Odds Ratio (M‐H, Fixed, 95% CI)	1.12 [0.85, 1.47]
4.2 Randomised on day of OPU or day 1	7	872	Odds Ratio (M‐H, Fixed, 95% CI)	1.04 [0.79, 1.37]
4.3 Randomised on day 2 to 3	1	118	Odds Ratio (M‐H, Fixed, 95% CI)	0.64 [0.31, 1.34]
4.4 Day of randomisation unstated	2	139	Odds Ratio (M‐H, Fixed, 95% CI)	1.23 [0.61, 2.49]
5 Clinical pregnancy rate per OPU Show forest plot	15		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Clinical pregnancy rate per OPU: grouped by number of embryos transferred Show forest plot	15		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 Equal numbers of embryos transferred	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 More cleavage stage than blastocyst embryos transferred	9		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Clinical pregnancy rate per OPU: grouped by prognosis Show forest plot	15		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.1 Good prognosis	7		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Poor prognosis	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Unselected	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Clinical pregnancy rate per ET Show forest plot	16		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10 Clinical pregnancy rate per ET: grouped by prognosis Show forest plot	16		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.1 Good prognosis	8		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Poor prognosis	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 Unselected	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Clinical pregnancy rate per ET: grouped by number of embryos transferred Show forest plot	16		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11.1 Equal number of embryos transferred	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 More cleavage stage than blastocyst embryos transferred	10		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Clinical pregnancy rate

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Comparison 3. Multiple‐pregnancy rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Multiple‐pregnancy rate per couple Show forest plot	12	1807	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.63, 1.13]

2 Multiple‐pregnancy rate per couple: grouped by number of embryo transfer Show forest plot	12	1807	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.63, 1.13]

2.1 Equal number of embryos transferred	6	1157	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.63, 1.32]
2.2 More cleavage stage than blastocyst embryos transferred	6	650	Odds Ratio (M‐H, Fixed, 95% CI)	0.76 [0.48, 1.21]
3 Multiple‐pregnancy rate per couple: grouped by prognosis Show forest plot	12	1807	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.63, 1.12]

3.1 Good prognostic factors	7	824	Odds Ratio (M‐H, Fixed, 95% CI)	0.75 [0.50, 1.12]
3.2 Poor prognostic factors	1	54	Odds Ratio (M‐H, Fixed, 95% CI)	0.89 [0.14, 5.81]
3.3 Unselected	4	929	Odds Ratio (M‐H, Fixed, 95% CI)	0.96 [0.62, 1.47]
4 High order pregnancies (more than 2 gestational sacs) per couple Show forest plot	10	1520	Odds Ratio (M‐H, Fixed, 95% CI)	0.44 [0.15, 1.33]

5 High order pregnancy: grouped by number of embryos transferred Show forest plot	10	1520	Odds Ratio (M‐H, Fixed, 95% CI)	0.44 [0.15, 1.33]

5.1 Equal number of embryos transferred	6	1157	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.28]
5.2 More cleavage stage than blastocyst embryos transferred	4	363	Odds Ratio (M‐H, Fixed, 95% CI)	0.46 [0.14, 1.49]
6 High order pregnancies: grouped by prognosis Show forest plot	10	1520	Odds Ratio (M‐H, Fixed, 95% CI)	0.44 [0.15, 1.33]

6.1 Good prognostic factors	7	870	Odds Ratio (M‐H, Fixed, 95% CI)	0.29 [0.08, 1.06]
6.2 Poor prognostic factors	1	54	Odds Ratio (M‐H, Fixed, 95% CI)	4.2 [0.16, 107.89]
6.3 Unselected	2	596	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Multiple‐pregnancy rate per pregnancy Show forest plot	12		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 High order pregnancies per total pregnancies Show forest plot	11		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9 Multiple‐pregnancy rate per pregnancy: grouped by number of embryos transferred Show forest plot	11		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.1 Equal number of embryos transferred	5		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 More cleavage stage than blastocyst embryos transferred	6		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Multiple‐pregnancy rate

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Comparison 4. Miscarriage rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Miscarriage rate per couple Show forest plot	10	1453	Odds Ratio (M‐H, Fixed, 95% CI)	1.36 [0.91, 2.02]

2 Miscarriage rate per pregnancy Show forest plot	11		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 4. Miscarriage rate

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Comparison 5. Embryo freezing rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Embryo freezing per couple Show forest plot	9	1416	Odds Ratio (M‐H, Fixed, 95% CI)	0.45 [0.36, 0.56]

2 Embyro freezing per couple: grouped by number of embryos transferred Show forest plot	9	1416	Odds Ratio (M‐H, Fixed, 95% CI)	0.45 [0.36, 0.56]

2.1 Equal number of embryos transferred	5	956	Odds Ratio (M‐H, Fixed, 95% CI)	0.42 [0.32, 0.55]
2.2 More cleavage stage than blastocyst embryos transferred	4	460	Odds Ratio (M‐H, Fixed, 95% CI)	0.51 [0.36, 0.74]
3 Embryo freezing per couple: grouped by prognostic factors Show forest plot	9	1416	Odds Ratio (M‐H, Fixed, 95% CI)	0.45 [0.36, 0.56]

3.1 Good prognostic factors	5	542	Odds Ratio (M‐H, Fixed, 95% CI)	0.41 [0.28, 0.58]
3.2 Poor prognostic factors	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Unselected	4	874	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.36, 0.62]

Comparison 5. Embryo freezing rate

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Comparison 6. Failure to transfer embryos rate per couple

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Failure to transfer any embryos per couple Show forest plot	14	1944	Odds Ratio (M‐H, Fixed, 95% CI)	3.21 [2.15, 4.81]

2 Failure to transfer any embryos per couple: grouped by number of embryos transferred Show forest plot	14	1944	Odds Ratio (M‐H, Fixed, 95% CI)	3.21 [2.15, 4.81]

2.1 Equal number of embryos transferred	6	1157	Odds Ratio (M‐H, Fixed, 95% CI)	2.67 [1.63, 4.39]
2.2 More cleavage stage than blastocyst embryos tranferred	8	787	Odds Ratio (M‐H, Fixed, 95% CI)	4.42 [2.18, 8.98]
3 Failure to transfer any embryos per couple: grouped by prognostic factors Show forest plot	14	1944	Odds Ratio (M‐H, Fixed, 95% CI)	3.21 [2.15, 4.81]

3.1 Good prognostic factors	7	800	Odds Ratio (M‐H, Fixed, 95% CI)	1.58 [0.65, 3.82]
3.2 Poor prognostic factors	2	77	Odds Ratio (M‐H, Fixed, 95% CI)	5.12 [0.93, 28.26]
3.3 Unselected	5	1067	Odds Ratio (M‐H, Fixed, 95% CI)	3.74 [2.32, 6.03]

Comparison 6. Failure to transfer embryos rate per couple

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Comparison 7. Cumulative pregnancy rate

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Cumulative pregnancy rate from fresh and frozen transfers Show forest plot	3	420	Odds Ratio (M‐H, Fixed, 95% CI)	0.58 [0.39, 0.87]

Comparison 7. Cumulative pregnancy rate

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