The more additional techniques, the better success rates? The medical evidence.

There are some conditions that we can treat, some of the conditions like maternal age that we cannot treat. I think that one of the most important factors is maternal age, especially for IVF with own eggs. I think that we all know that when we go over 38 or 40 years old we have high risks of repeated failures, and also recurrent miscarriages, and we cannot change that. That’s why when we have patients over 43 – 44 most of them will finally decide to go on with egg donation or embryo donation programs. There’s no chance to treat the quality of these eggs, but we have the option to use the donor’s eggs or the embryos that have been donated by some other couples. There are some other conditions like an ovarian reserve or egg reserve that sometimes we can just diagnose, like in the cases of endometriosis or those patients that have had surgeries on the ovaries there are some specific treatments that we can do. Especially on ovarian stimulation to try to increase the quantity and the quality of eggs that we can get on the retrieval, but again we cannot change the patient’s ovarian reserve and in those patients, even in young patients that have almost none ovarian reserve – the only option would be a donation. There are some other conditions like the uterine factor which means that the uterus has an abnormal shape or the endometrium has some problems. That we can diagnose, and we can treat them before starting any treatment, usually by minor and simple techniques, like hysteroscopy where we’re able to see the cavity or to see if there’s something wrong inside that is giving it repeated failures or recurrent miscarriage. Treating those can increase the chances of implantation.

To check if a male factor is involved, spermogram sometimes is not enough to give us a precise diagnosis. We know that probably around 50 per cent of failures in egg donation programs is due to an unstudied male factor or a male factor that hasn’t been diagnosed yet. In our clinic, we study male factor before studying any IVF treatment and any egg donation treatment, which is very important. We start with an interview with the chief of andrology, we perform an examination, and we are doing some specific tests depending on the previous treatments which the patient or the couple already had. Some tests can be done like DNA fragmentation or FISH in semen samples, that can give us sometimes the idea of the risk of repeated miscarriage if DNA fragmentation is high or the risk of abnormal embryos when FISH is abnormal. This is done on semen samples, but sometimes we need to do the biopsy to discover if there are abnormalities in chromosomes of spermatozoa. When we have this male factor, and we already have the diagnosis, there are some techniques that we can use, such as specific sperm selection techniques as PICI, IMSI, Fertile Chip. Those can help us selecting the healthiest spermatozoa to try to increase the fertilization rate and to increase embryo quality up to a blastocyst stage. These techniques depend on the diagnosis, and if chromosomes are abnormal. We always have the chance to use PGT-A which is prenatal genetic testing. We can make sure that even if we are creating some embryos with an abnormal number of chromosomes, we can study these embryos and will be able not to transfer them. And only transfer those that are normal and have a normal number of chromosomes.

I have already mentioned uterine abnormalities and endometriosis, which I think are the most important gynecologic conditions. Some other gynaecological conditions can also lead to failures. Patients who had any uterine or ovarian surgeries. Also in those patients that had oncological treatments where they had survived ovarian cancer or uterine cancer or even breast cancer. That will mean they have poor or almost no ovarian reserve. These patients should be evaluated by a multidisciplinary committee. We do have an oncofertility committee which can evaluate cancer survivors and guarantee that we’re not increasing the risk of cancer and we’re giving them the highest success rates to achieve the chance of having a baby.

In repeated implantation failure we know that up to 70 per cent of cases is due to embryo abnormality – so an abnormal number of chromosomes. This will be increased in those patients over thirty-five, and 38 and 40. We know that at 38 probably 70% of the embryos will be abnormal, at 40 probably 80-85 % of the embryos will be abnormal, and between 43-45 probably almost 99-100%, so almost all the embryos will be abnormal. Those abnormal embryos would either not implant and cause repeated failure or will cause early first-trimester miscarriage. Therefore, PGT-A which refers to prenatal genetic testing for the aneuploidies will help us avoid transferring these abnormal embryos and reduce the chances for negative tests and reduce the chances for repeated miscarriage. It doesn’t matter if it comes from the ovarian factor or genetic male factor. F. e. with an abnormal karyotype or an abnormal number of chromosomes in the spermatozoa. PGT-A will reduce the chances of repeated miscarriages and repeated failure because we are avoiding to transfer those embryos that are not able to implant or that will implant and will always end up in an early miscarriage. So PGT-A can be very useful, in some specific cases. Sometimes it can be used in those patients that want to make sure that they are transferring a normal embryo, even if there is no risk factor, it will reduce the time to give us an evaluative pregnancy and healthy baby.

In egg donation cycles we are reducing the chances of chromosomal abnormalities coming from the egg, just because we’re using eggs from donors who are between 18 or 33-35 year old, so we’re reducing the risk of aneuploidies quite a lot. In those patients where we suspect male factor and genetic male factor, PGT-a will reduce the chances of transferring an abnormal embryo. And in those patients that just want to make sure that we’re transferring a normal embryo, even if we do not have a male factor and we’re using young donors eggs. PGT-A will help to avoid any transfers that we shouldn’t be doing. PGT-A is always an option with a medical indication or as an elective technique.

I think that all the additional techniques that have appeared in the last ten years, almost all of them are connected with the laboratory. Almost all of them are connected with the egg, with the spermatozoid, with the embryo fertilization, and embryo development. We’ve been able to increase the chances and the pregnancy rates probably by 15-20% during the last ten years, but it’s been only due to these additional techniques in the lab. We still have a lot of research to do related to implantation and endometrium, that’s the part we should be focusing on in the next 10 years. There are many trials related to repeated failures because of many factors related to the endometrium, but there is still low scientific evidence on most of them. Following the guidelines of the European Society of Human Reproduction (ESHRE), the only cause for implantation failures are uterine abnormalities, which means f.e. having a double uterus, uterine septum etc. That’s the only strong evidence. If we diagnose it and we treat it, we’ll able to reduce those repeated failures. There are some diagnostic techniques related to the endometrium such as endometrium cultures, endometrial biopsy and many studies that we can do on the endometrium are related to the microbiota, the implantation window or immunity. We still need further clinical trials and randomized clinical trials to tell patients that these tests will give us the cause for implantation failure, and then the treatment will increase the pregnancy rates. I think it’s too early to tell the patients that we have strong scientific evidence on all these tests that can be done on the endometrium. There’s another factor which is adenomyosis, which is endometriosis just under the endometrium in the muscular part of the uterus. Some trails show that adenomyosis will reduce the success rates and that probably some treatments could help us increasing the results in this group of patients.

When we are referring to quality we need to talk about mature and immature eggs. When we’re stimulating the ovary, we try to get a high number of high-quality eggs. The first thing we need to talk about is mature and immature eggs. There are different protocols and different techniques to change ovarian stimulation in those patients that already had a high rate of immature eggs retrieved, and also there are some techniques to try to mature these immature eggs inside the lab. Some of them are still experimental techniques, we can get some mature eggs from immature eggs, but at this moment trying to improve maturity during ovarian stimulation is the gold standard. And, in those patients that had poor results and a low number of mature eggs, we’re supposed to change the protocol to try to increase the maturity and improve the maturity of these eggs. There are some other aspects related to quality, and they have to do with maternal age. Unfortunately, we cannot treat the age of the eggs. We know that man will produce million of spermatozoa every single day but, in the case of oocytes the woman will be born with a precise number of eggs and the quantity and the quality will be reduced every single year, especially in women over 35-38-year-old. So in this aspect, we cannot change or improve the quality of the eggs.

Time-lapse technology has become very important now that the gold standard is going to day-five blastocyst stage transfers. 10 or 15 years ago when we used to transfer embryos on the day – 2 or day – 3 there was no sense with using time-lapse technology. We know that half of the embryos probably will get blocked when we’ll try to wait for the blastocyst stage. We also have so-called blastocyst rate, which means how many high-quality blastocysts we get on the average of total embryos create. Trying to keep the best conditions for embryo development is important, and Embryoscope or any other time-lapse technology will help us get the same temperature, same humidity, the same conditions inside the incubator. Just because we don’t need to open it every single day for every patient. It allows us to get a picture of each embryo every 5-10 minutes, and we’ve been able to see many aspects of the morphokinetics of the embryo development up to day five. It will help us choose the embryo that has the highest possibility of resulting in a pregnancy. We’ve seen that some of these abnormal divisions which might happen during development, can be fixed by the embryo. Sometimes, there are some abnormalities on day-2, day-3 that if the embryo can fix and develop to high-quality blastocyst, we can use it. That will give us the same pregnancy rates that another embryo that had the same problem and wasn’t able to fix it. Only with this time-labs technology we’re able to get these little details during embryo development that will give us a prognosis. Another thing is being able to watch the embryos in real-time at home. Here at the Institut Marques, we give patients the opportunity through the embryo mobile technology to enter the lab virtually and be able to watch the embryos on real-time for the five-six days of culture. There was a very nice clinical trial that we presented last year at the ESHRE Congress which showed that those patients who connect to watch the developing embryos many times a day were able to get up to 11% higher pregnancy rates. It was probably due to psychoneuroendocrinology effect coming from emotions and going down to immunology on the endometrium and being able to watch this embryo and getting attached to it, and the treatment just gave them a higher possibility to get a positive test.

In 2018, I believe it is the latest data that we got from the European Society of Human Reproduction. There were 50,000 of egg donation cycles done in Europe and from those 25,000 were done in Spain. There are many reasons for that, first of all, I think that it has to do with the recruitment programs that we have for donors. There are differences in some countries like in France where the donors cannot get any compensations for the treatment. In Spain, it is allowed to give compensation even though it’s not a high compensation, just good enough for the days that they cannot go to work etc. Getting half of the egg donation treatments in Europe, I think that has given Spain the possibility to develop this high-quality recruitment programs for donors. Trying to get good matching with the patients and being able to select the best one for each patient. In our unit, we have hundreds of active donors that are waiting to start treatment, but it depends on the blood type, on the physical characteristics etc. and then we need to know when will they be ready to start for a specific patient. The number of donors that will be starting the treatment depends on the number of patients that will come and start treatment in our clinic. We’re getting patients for more than 50 countries coming for egg donation programs, and of course, we do have donors from all ethnicities, all physical characteristics.

We are the only clinic in the world at this moment that gives the opportunity to connect from your phone, your tablet or any mobile device to our laboratory during the embryo culture days. Patients will receive an encrypted link to the email address, and they or sometimes the referring clinicians can click on this link and connect as many times as they want. Our clinical trial on watching these embryos was dividing patients on how many times they connected every day, we have patients that connected once a day, some of the patients that connected up to 10 times a day. The group of patients that were able to get the highest pregnancy rate were those patients that connected up to 30 times during the whole culture, which means around five-six times a day. You can see if you have five embryos, you will see five images, and you can update it every five minutes, so you’re able to keep on tracking the development of your embryos, and see how they develop even if you are 10,000 miles away. It’s quite a nice technology.

I think guaranteeing blastocysts is fantastic but of course in egg donation programs what we can guarantee is the quantity and the quality of the eggs. However, we cannot guarantee the quality of sperm, so being able to guarantee a specific number of blastocysts, in my opinion, is not fair. If we have a severe male factor, we need to tell the patients that probably we won’t be able to get a high number of the high-quality blastocyst and we need to look how to increase these chances of getting high-quality blastocysts. The number of blastocysts is important but being able to make sure that the quality of these blastocysts is the one that we tell, is what the embryo mobile technology gives to the patient. If we have poor quality blastocysts, and this blastocyst will never be able to give a pregnancy, this doesn’t count we should never transfer this embryo we should never freeze these embryos. Allowing the patient to keep the recorded video of all the embryo development, gives them also the chance for a second opinion and make sure that if we transfer to high-quality blastocyst – they can verify it. The average of the blastocyst that we can get in our program, the last data that we had is 2.8. This means that some patients will get 6 blastocysts, some other patients will get 1, it depends not only on the quality or quantity of the eggs, but it also depends on the male factor.

When we talk on endometrial factor, I think there is still little evidence about using any compound inside the uterus during the transfer, before the transfer. There were many ongoing clinical trials on growth factors insulated inside the uterine cavity or some other products that we can use during or before the transfer to increase pregnancy rates. At this moment, there is not enough medical evidence. We used to see patients that had many treatments, they had done many additional techniques related to the endometrial factor. I think that using EmbryoGlue or using any other techniques without having tested if the embryos are normal by PGT-A – is not worth it. Before using any low evidence technique, I would strongly recommend using all the strong evidence technique that we have. As I’ve mentioned, we see many patients that had many treatments without doing almost none of those strong evidence technique, and they had done many low evidence techniques just before doing the right things. After using all the available techniques with strong evidence, if we still have repeated failures, there are some other techniques that we can add, but never the other way around.

At 40, I think that the most important thing is egg quality and egg quantity. We are not able to proceed with treatment now due to COVID-19 situation, but we might be able to get some tests done. It depends on the country and the region of course, in some countries you can only go to your doctor for an emergency, you cannot go for standard tests. I think that all doctors, and in many countries clinician are just working to fight this epidemic. But, if the patient has the opportunity to check the ovarian reserve such as the Anti-Müllerian hormone (AMH) or do an ultrasound to check the Antral Follicle Count (AFC), – I think that you could already know your chances. You could get familiar with the PGT-A, as getting all the information about the treatment that you are supposed to do, is important and getting the right information from the right clinicians is important, and being able to ask any questions you might have. Keep in mind, that we can lose this month or we can take the advantage of it and get all the information about the treatment and having the opportunity to get a virtual appointment with a specialist is the best thing you can do now.

The agonist protocol in women over 40, usually they are low responders, which means less than nine or less than five eggs for each ovarian stimulation. There were different protocols for low responders both with antagonist and agonist. Probably so-called long agonist protocol will give us the highest quantity and the highest quality of eggs. We can also try and antagonist protocol, called ultrashort protocol with high doses, both are possible, but probably the latest evidence shows that there is a little advantage to long protocol with agonists.

PGT prenatal genetic testing is related to all the tests that we can do on the chromosomes and genes of an embryo. There are different PGT’s, PGT-A looks for the number of chromosomes, PGT-M is for specific genetic monogenic diseases which are families that have a recessive disease. NGS is related to the technique where we’re doing that, so you can have PGT-A using NGS. There are different types of testing, a few years ago we had the FISH studies for PGT, and now we have the gene sequencing so we can sequence almost all the genome from an embryo. So you need to keep in mind that PGT is the reason why we’re doing the technique, and NGS is the technique that we’re doing to get the diagnosis.

We’ve been using EmbryoScope for many years. It has to do with the results that we have with the EmbryoScope technology, but it also has to do with the technique that we use to share this image with the patients. We’ve never tried to share the data from GERI device. We use EmbryoScope in all our labs around Europe. We do not have any other devices like GERI because we used to use EmbryoScope from the beginning. Also, because we use the embryo mobile technology we wouldn’t be able to use it with GERI, this is very important for us, to be able to share this information with all our patients. Many trials are comparing time-lapse technology devices, we cannot say that there is a winner from a scientific point of view. I believe both of them will keep the best conditions for embryo development, of both of them, are closed incubators, so we do not need to get the embryos out every single day. So at this point, I think that probably they’re both the same and the difference is the specialist software related to how we do evaluate the images that we get from GERI and the EmbryoScope. So yes, we recommend EmbryoScope to all our patients. We use conventional standard incubators to heat the plates for the next day, but I think we rarely have developing embryos in standard incubators. Almost all of our embryos will grow in time-lapse incubators.

Probably I’m not the right person to answer this question as I am not an embryologist. I know that we’re testing different media cultures, especially now we’re going up to day-5 in the time-lapse incubator. In most of the cases, we need to use a single media culture which means the same culture for the five days. There are some differences, as we now have moved, I guess that 95% of our transfers are on day-5, so it’s one of the most important parts. The embryo in the incubator stays static – it won’t move. So many years ago we started the trial to see the effects on music during this culture just because we know that in nature the embryo will move through the fallopian tubes for four days and, in the incubator, the embryo stays still during these days of embryo culture. Some toxin will accumulate around the embryo, and the oxygen and other nutrients will go a bit further away from the embryo, just because the embryo will stay static. So we play music inside all of our incubators to try to move this media culture and avoid this toxicity during embryo development that happens inside the incubator. It is moving this media culture with musical vibrations, and we already presented that we can increase fertilization rate up to 5% using music, and we can increase embryo development and improve every development applying these musical vibrations during embryo culture. I’m sorry that I cannot answer or advise on those EmbryoGen and BlastGen, an embryologist will be best to answer them.

There is a large project of research that we did. We started it in 2012, we wanted to check the effects of music at early stages of life. We started with music inside the incubators, and then we continued with music during early pregnancy. We developed two specific devices called the baby part to play music during pregnancy, but not through the belly – through the mother’s vagina, and there’s a whole project on the effects of music specifically during embryo development inside the incubators. As I already told you, we saw an increase of fertilization and blastocysts rate, but of course, it doesn’t matter if it’s heavy metal, rock, pop or classical music because all of them, will give us this media culture movement just because of the mechanical vibrations. We found that we were able to increase the rates, but we didn’t find any significant difference depending on the type of music. All of our embryos which are inside the incubators have a 24-hour concert inside the incubator. Last year, we had many concerts in our laboratory, we invited Sharon Corr from The Corrs and Álex Ubago, both came to our laboratory to play a concert to all of our embryos around Europe, in all of our laboratories. All the patients had the opportunity to watch the concert and at the same time to watch the developing embryos which from an emotional point of view, was fantastic.

It’s included, as I said almost all of our patients use time-lapse technology and it is one of the reasons they choose it. I think it makes sense to give the opportunity to get the best embryos and to see it.

Adenomyosis is quite an important condition for repeated implantation failure. It depends on the degree and the average of the uterine cavity, which is affected by adenomyosis. Some patients have just little focal adenomyosis which doesn’t have any effect on implantation. Some patients have pain during the period – they have severe adenomyosis. In these patients, we need to stop this activity under the endometrium to reduce inflammation and to increase chances for implantation. Using some treatments like agonists before the transfer it is one of the options. Some patients with focal adenomyosis probably will need one month of treatment, and it will be enough. In some of the patients that already had implantation failure, and they have severe adenomyosis, sometimes a three-month agonists treatment is mandatory before transfer to increase the chances of implantation. So from 1 to 3 months of treatment before the procedure.

For sure, for fertility but for any health purpose we should recommend reducing any toxics, any drugs, of course, smoking should be avoided and alcohol as well. Having a healthy diet, exercising has shown to decrease the problems, especially the problem of DNA fragmentation in male condition. I see that he’s been taking antioxidants, which is good in reducing the fragmentation but be careful not to do it for more than 4-6 six months. We could have a rebound effect, so if the andrologist just told you to take this omega-3 or undergo antioxidative treatment, you should do it for eight or twelve weeks before treatment but no more than that.

Time-lapse technology allows keeping the embryos inside the incubators for all the embryo culture days, which means between 5-6 days. There’s a camera inside that will take a picture every 5-10 minutes without the need of getting the embryos out, putting them to the microscope, taking the photo and then putting them back again. If there was one incubator per patient we would open the incubator once a day but, in standard incubators, you will have 10, 12 or 15 patients keeping their embryos inside. We would need to open the incubator 10-20 times a day to see an embryo, and before the transfer, if you needed to reobserve an embryo you could double these numbers. This doesn’t happen in time-lapse technology where you can get the embryo out just for transfer, and you don’t need to take it out during embryo development. I think that yeah there are different options in time-lapse technology, and as I said before, I think every lab has its routine, and they know their results based on the incubator they are using for embryo culture. Here in Institut Marques, we’re happy with Embryoscope because we can also add the embryo mobile technology.