Should I have a Day 3 embryo transfer or a Day 5 (blastocyst) embryo transfer?
Recent advances in the laboratory has led to the development of new culture systems capable of growing embryos beyond the Day 3 stage and to the Day 5 or blastocyst stage. This is achieved by using not one, but a sequence of culture media, each designed to meet requirements specific to each preimplantation stage. The availability of a number of successful sequential culture systems has led many programs of assisted reproductive technology to pursue blastocyst production and replacement.
The principal indication for Day 5 or blastocyst transfer is the reduction of ART-associated multiple pregnancy.
Approximately 40% to 60% of fertilized oocytes reach the blastocyst stage using contemporary sequential culture systems, but there are remarkable variations a patient’s ability to produce blastocysts. A risk of attempting blastocyst transfer is the possibility that no embryos will be available for replacement.
It is best to check with your individual clinic to assess the availability of and the clinic’s experience with blastocyst transfer.
Should I have my IVF center perform Assisted Hatching on my embryos before transfer?
In vivo hatching of the blastocyst is a critical component of the physiologic events culminating in implantation. Conversely, the failure to hatch may be one of the many factors limiting human reproductive efficiency. The clinical application of assisted hatching has been proposed as one approach toward the enhancement of implantation and pregnancy rates following in vitro fertilization.
The assisted hatching procedure entails the creation of a gap in the outer area of the embryo called the zona. This is done either by drilling with an acid medium, by laser, or by using a piezomicromanipulator.
Success rates following the use of assisted hatching in different ART programs have varied considerably. Well-designed studies suggest that assisted hatching might best be used in patients > 38 years old or with multiple prior failed IVF cycles
How many embryos should I have transferred back?
The objective of infertility treatment should be the birth of a single, healthy child. Many of the treatment options presented to infertile couples, however, are associated with high risks of multiple gestation. Moreover, many couples view multiple gestation as desirable and are unaware of the risks they pose to both mother and babies. Couples should understand these potential risks before starting treatment.
The ability to limit the number of embryos or eggs transferred is an effective approach to limit multiple pregnancies. The Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) have published guidelines recommending an optimal number of embryos for transfer based on patient age, embryo quality, and other criteria.
See http://www.asrm.org/Media/Practice/NoEmbryosTransferred.pdf
In the United States, the decision regarding the number of embryos to transfer is made jointly by the physician and the patients. This decision should be based upon the best interests of the patient and the future offspring. However, ART is centrally regulated in England, and no more than three embryos may be transferred in most circumstances. In Canada, a recent Royal Commission recommended the transfer of a maximum of three embryos.
The ultimate goal is to achieve a high pregnancy rate while transferring a single embryo. Recent laboratory improvements have allowed programs to transfer two embryos while maintaining acceptable pregnancy rates. Eventually, the transfer of one embryo will resolve the issues surrounding multiple pregnancies.
Some clinics see more than the average number of patients with difficult infertility problems. Some clinics are willing to offer ART to most potential users, even those who have a low probability of success. Others discourage such patients or encourage them to use donor eggs, a practice that results in higher success rates among older women. Clinics that accept a higher percentage of women who previously have had multiple unsuccessful ART cycles will generally have lower success rates than clinics that do not. In contrast, clinics that offer ART procedures to patients who might have become pregnant with less technologically advanced treatment will have higher success rates than clinics that do not.
Why should my doctor be a SART member?
To ensure that a patient receives high quality care, they should seek a doctor who has attained SART membership. The purpose of SART is to set the standards for the practice of IVF by providing its members with strict guidelines that optimize reproductive care for patients.
SART is the professional society for doctors and laboratory scientists who work together as a team to provide services in assisted reproduction. It is an affiliated society to the American Society for Reproductive Medicine (ASRM). SART is the place for these professionals to share information and experience. Many SART members meet on a regular basis at the annual ASRM meeting.
SART has rigorous requirements for membership. SART members must agree to: 1. Report all their pregnancy data yearly. These data are subject to validation (a modified audit) by a team comprised of the CDC and the SART validation committee. This validation includes a site visit to the SART member’s clinic and review of the medical records. 2. Embryo laboratory inspection and certification every two years by an outside agency, usually the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the College of American Pathologists (CAP). 3. Abide by all practice, laboratory, ethical, and advertising guidelines. 4. All new practices must have a board-certified reproductive endocrinologist as medical director.
Patients seeking IVF services can be reassured that a SART member has satisfied these rigorous requirements.
What is validation?
Federal Law requires the publication of assisted reproductive outcomes from all clinics providing such procedures in the United States. Validation is the process whereby, through random sampling, the veracity of the entire dataset to be published is established. This process is performed by the Validation Committee in conjunction with the CDC. The Validation Committee is composed of fourteen professionals from both SART and non-SART member programs. Sites to be visited (currently forty) are randomly selected by the CDC, with site visits performed by teams of two Validation Committee members. Currently, about twenty variables are validated from 50 randomly selected cycles. Additionally, all live births reported by the clinic are validated. The data collected from site visits are compiled, and reviewed jointly by the CDC and the Validation Committee. Programs are notified regarding the overall outcome of validation and their specific program results.
Do I need Pre-Implantation Genetic Diagnosis (PGD)?
While PGD was first developed in 1990, its use is recently gaining widespread support due to improvements in molecular biological detection of genetic disease. The main purpose of PGD is to help physicians select embryos unaffected by specific genetic diseases to transfer. With assessment of embryo quality it has always been a challenge to find the one embryo most likely to result in a healthy baby. The principle parameters used to date in embryology labs are the morphology (appearance) and development of the embryo over the short time it resides in the lab. PGD involves a biopsy of the early embryo to assess the genetic make-up of the cells removed. This allows physicians to choose those embryos that do not have genetic abnormalities in hopes of optimizing the outcome of IVF.
Incredible improvements have been developed over the past five years that allow greater genetic assessment with better accuracy. There are an increasing number of single-gene disorders, like cystic fibrosis or sickle cell anemia that can be diagnosed in the embryo before implantation. By not transferring the affected embryo, the disease state can be avoided in the child.
Preimplantation Genetic Screening (PGS) embryos can be screened to detect chromosomal abnormalities (wrong number of chromosomes) that may lead to miscarriages, an abnormal fetus, or abnormal embryos which do not implant. By choosing the embryos with normal chromosomes, the hope is to improve the chance of having a healthy baby. However, evidence so far has not shown that miscarriage rates or delivery rates are improved, though new technology may hold promise. Most patients are likely not helped by PGD as embryos do appear to grow less well after biopsy.
Many studies are being done currently to determine who are the best candidates to undergo PGD. It is best to discuss this with your physician to see if it is an option for you.
Do I need intracytoplasmic sperm injection (ICSI)?
The purpose of ICSI is to assist the fertilization process when a man’s sperm count is abnormal. Whether it is because the number of motile sperm is very low or the morphology is excessively poor, the technique involves the delivery of a single sperm into a single egg. Since 1991, when it was first described, it has revolutionized the treatment of male infertility.
Most clinics will recommend ICSI if there is a fear that poor fertilization may occur by traditional IVF where sperm are merely added to the egg culture dish. Accordingly, efforts are made to assess sperm by function or morphology to help determine those most likely to require ICSI. It is best to discuss this option with your clinic personnel prior to treatment.
Do I need donor eggs?
A principal limitation to human reproduction is the natural loss of healthy eggs as a woman ages. At birth, a woman is born with her total reserve of eggs – no more are created. Over her lifetime, waves of them degenerate through a natural process called atresia so that by her mid thirties, we begin to see a greater difficulty to achieve a pregnancy and a higher chance of chromosomally affected children. By her early forties, the majority of women experience infertility and eventually a loss of reproductive capacity. This is due to the eventual loss of her remaining healthy eggs.
Egg donation, like sperm donation, is a means to realize parenthood when the loss of gametes (i.e., egg or sperm) occurs. This may be due to the natural process of aging or may occur prematurely from other disease states or because of medical treatments for cancer, for example. When gametes are depleted, replacement by egg donation is a wonderful option to enable one to become a parent.
There are many young women who want to help others overcome infertility. They serve as egg donors by expressing interest and then going through a rigorous screening process to ensure they are appropriate candidates. Typically, they provide a detailed health history of themselves and genetic history of their ancestors. Medical and psychological evaluations are performed, in addition to FDA mandated infectious disease testing.
Once a patient has chosen to pursue egg donation, the process typically involves coordination of their two menstrual cycles so that the eggs may be retrieved, fertilization by the sperm of the patient’s partner and transfer into the patient’s womb can occur during the same month. The egg donor treatment cycles rate among the highest success in assisted reproduction.
What is third party reproduction?
The first and second parties involved in a pregnancy are the male and female couple wishing to become parents. The three principal components required to achieve a successful pregnancy are a healthy egg, sperm and uterus. If any of these components are absent, then an option is to have a third party, or someone besides the couple, become involved. Third-party reproduction is when a couple uses a sperm donor, egg donor or a gestational carrier to help them become parents.
Each third party becomes involved in very distinct and completely different ways. A sperm donor’s involvement, for example, may simply be to produce a semen sample at a sperm bank, while a gestational carrier is committed for at least the nine months of pregnancy. Each has its own intricacies, processes, regulations and procedures that a certified IVF center can help a patient navigate through. It often involves a multi-team approach including the reproductive endocrinologist, the IVF team, an experienced attorney, a psychologist, third-party agencies, etc.