What you should consider when choosing an IVF clinic?
Selecting a fertility clinic that you will be comfortable with, a clinic that boasts high pregnancy rates, employs English-speaking coordinators and friendly, experienced doctors can be a daunting task. Especially when you are considering infertility treatment abroad. We have invited Dr Laura García de Miguel to tell you more about the process of selecting an IVF clinic. What is important? Are pregnancy rates the main deciding factor? Does cheap IVF cycle mean poor quality treatment and expensive program ensures success? Watch the webinar recording above to find out the answers to these questions.
How to choose the right IVF clinic?
IVF is an incredibly frightening road to embark upon and the prospect of choosing a clinic can often leave patients feeling overwhelmed, full of questions and uncertain about where to go. With the popularity of overseas treatments rising it can be confusing for clients to even know how to begin finding a clinic, let alone understand what exactly they should be looking for to ensure a high level of service is adhered to.
In this webinar, Dr Laura Garcia de Miguel, Gynaecologist, Obstetrician and Medical Director of Clinic Tambre in Madrid, outlines the most important factors patients need to contemplate when choosing a fertility clinic abroad.
The first consideration is how much experience a clinic has. Patients should be looking for a medical centre which has been practicing for over twenty years and carries out frequent treatments.
It is usually expected that Doctors and Embryologists will have at least 5-10 years of experience and be educated to Master’s Degree level. Good doctors will also have specific training in reproductive techniques and Embryologists, across Europe, will have an ESHRE (European Society of Human Reproduction and Embryology) certificate.
When researching a clinic’s laboratory patients should enquire how many embryologists there are and whether it is an appropriate number for the amount of cycles the clinic performs. It is also worthwhile finding out whether the team specialise in genetics and if they offer additional treatments such as blastocyst biopsies. It is crucial to understand what technologies are available, and what impact these may have upon a positive treatment outcome.
For instance, time-lapse incubators are associated with increased pregnancy rates as they provide around the clock imaging with uninterrupted culture conditions; embryologists do no need to remove the cells to look at their progress. As a result, it is thought that the use of a time-lapse incubator provides a better chance of having a blastocyst (day-five embryo) transfer. It’s the same with PGS (preimplantation genetic screening), if clinics can provide a blastocyst screening process then only euploid (chromosomally healthy) embryos are selected for transfer, which can then reduce the risk of implantation issues and/or early miscarriage.
Dr Garcia de Miguel always advises choosing a clinic which practices ‘double checking’, this is where two embryologists check the same embryo at every step of the process. ‘Witness’ or other similar clinic systems are also advisable, as these detect and monitor all activity within the lab. Personal barcoded ID cards should always be provided, again to help prevent any possible errors which have the potential to occur.
If clients are requiring either egg or sperm donation IVF then it is important to understand how many donors are available and whether there is a waiting list, specifically for fresh oocytes (eggs). Patients should also confirm the donor recruitment criteria, what screening processes are used and whether fresh and/or frozen gametes are being advertised or can be obtained for treatment. Dr Garcia de Miguel recommends that for an egg donation program, clients should not go to clinics which regularly transfer multiple embryos, and that success rates should be in the region of 65% per transfer. She advises the best clinics typically guarantee at least one good quality blastocyst, per cycle.
All clinics are fully aware that patients are influenced by success rate statistics, which is why it is essential to research and fully comprehend any data. In Spain, results should be audited by a third party and reported to the Fertility Society.
Dr Garcia de Miguel would expect that, in general, a good clinic’s success rate will be above 40% for IVF and above 65% when PGS is used. Again, her recommendation is to avoid clinics which repeatedly transfer more than one embryo as standard.
Dr Garcia de Miguel stresses the importance of using a clinic with a multi-disciplinary team. Clients should enquire what range of treatments are performed, at the clinic, and whether specific units, such as urology, psychology and immunology are available. As every person and their fertility is unique, the knowledge amassed in multi-disciplinary clinics enables patients to be treated more as individuals, rather than simply taking a standardised approach to treatment.
Finally, a good IVF clinic abroad is likely to have a patient care department available to help clients with every aspect of the process, including airport transfers and assistance with booking hotels close to the medical centre. It’s also key that staff are fluent in other languages and are prepared to offer multiple ways of contact, from Skype to phone calls, email and What’s App. Whilst infertility is a business and science, Dr. Garcia de Miguel reminds us that the human approach must not be forgotten. It’s imperative clinics remember patients are real people; people who are undergoing difficult treatments for the chance to, one day, hopefully, become a parent.
Questions and Answers from the event
Why do you advise against multiple implantation?
This is a topic usually we need to cover with our patients because usually many patients prefer to transfer more than one embryo. So, our objective is to have a healthy baby and a healthy mother after the delivery. If we transfer more than one embryo, you should know that embryos can divide themselves. For instance, if I transfer two blastocysts we could have a pregnancy of two babies but also there is a little possibility of having a pregnancy of three and even four babies. So, let’s imagine if we have a pregnancy of two or three, we will then run a high risk of incurring some pathologies such as problems of hypertension and preeclampsia and this would normally lead to prematurity deliveries and prematurity deliveries under 28 weeks can lead to very important chronic problems for the children.
What is the difference in using fresh or frozen eggs when using donor eggs?
The main difference is if frozen eggs are used, we need to deal with a larger number of eggs because we need to thaw them out so in terms of the resource, there is no major difference but we should count on a higher number of oversights if the cycle is realized with frozen eggs. For instance, in our clinic, we recommend using a fresh donor if there is no need to plan the transfer for a particular date. But when a plan is needed because of problems of organization, the job, etc., then it’s most convenient to do it with frozen eggs that can allow us to program the cycle.
What is hyper-stimulation syndrome?
This is a syndrome that can appear after the in-vitro process which means when we are stimulating with the subcutaneous hormones if the estradiol level is more than 3,000 and we obtain more than 15 eggs, then there is the risk of having a hyper-stimulation syndrome which means that the liquid of your body is going to go through the third space which means in the abdominal area and other areas. This is a very important issue to avoid because there’s no need to take that much risk. We recommend doing normal simulations which means not a very high dose—no more than 300—and then no matter if the estradiol or the eggs are very high, then we should freeze all the embryos and prevent that syndrome in the trial transfer in the next cycle.
Could you let us know the percentage of good clinics in Spain with your criteria?
Interesting. I really don’t know about the criteria of the other clinics in Spain. I would say that Spain is a country with a long experience in this type of treatment but I cannot say that 100% of our clinics work with these high standards or not so I guess, perhaps, 50% or 75% maximum would go with these criteria but not all the clinics.
How can we get information about the laboratory. Can we simply ask the clinic?
I guess you can ask the patient care department or the gynaecologist directly and ask for the details about the lab and they will just answer all your questions.
Do you advise a clinic that offers embryo adoption?
Yes, we do embryo adoption. It is a normal practice. Not all the clinics offer this service but we definitely do.
What does the open donor 18+ plus mean, which I saw on your website?
This means that Spanish law allows us to simulate, I mean to choose donors between 18 years and a maximum of 35 years old, so in general terms our donors will be more or less in their twenties.
Why do 50% of embryos not make it past day 3? is this due to poor quality sperm or a problem with the egg?
This is the percentage in general human development. It’s not a problem regarding the techniques or sperm. It’s the general rate of all the embryos of all the human embryos no matter if it is during the natural cycle, during sexual relations, or in laboratory techniques. So it’s a question that the embryo is very important at the beginning and has a very small number of cells so not all the embryos would reach the blastocyst stage.
Can we trust clinics that offer guarantee programs? For example, they say that you get back 80% of the money if a pregnancy wasn’t achieved.
I would say yes you can trust these clinics but the problem is that in general not all the patients can apply for this guarantee. Only the good prognosis patients can join this program so then these good prognosis patients don’t need to pay this large amount of money. By contrast, the poor prognosis patients will not be accepted for these guarantee programs and then it’s not worth it.
Why do most of the clinics—I would say 99%—provide information about success rates as pregnancy per transfer. I mean, the IVF with own eggs program, and not the pregnancy per cycle or would it be better to show live births per cycle?
I totally agree with you but the problem is that sometimes the follow-up of these patients in Clinica Tambre we usually do a very individual control of our patients and we call them back if they are in other countries when the pregnancy test must be done and then we do a follow-up for all pregnancies in the first three months, at 20 weeks and also after the delivery. The problem is that sometimes there are patients who do not answer our questions or do not answer our emails so we cannot provide data about our delivery rates. I would say that you should decrease the rate that the clinics offer by at least 10% — at least 10 to 15% of the live births per cycle.
Is there any difference in success rates in using fresh embryos compared with using frozen embryos?
As I said during my presentation regarding blastocyst embryos which means that they are embryos that have reached day 5, they are good quality embryos. There may not be a very huge difference between fresh and frozen but I would say fresh embryos transferred day 5 would be around 65% and then for frozen embryos the most important aspect is the thawing but if they survive the thawing then the pregnancy rate can increase 5 to 10%. We have many patients who achieved pregnancy with cryo-transfer but not with the fresh transfer so it’s more or less the same pregnancy rate.
Can I import frozen donor eggs from South Africa? They offer pictures of donors as a child. It’s still anonymous.
I would say that donors that work in our clinics or in Spain need to be compliant with Spanish legal regulations. So, you cannot have a picture of your donor so I’m sorry but this cannot be accepted.
Why is it better to use a day 5 egg than day 3?
In general, it has been already confirmed that day 5 embryos have a higher implantation rate compared to day 3 embryos. Of course, it is nearly impossible to check this little difference because the embryo cannot be transferred two times — I mean, day 3 and day 5 to check which strategy is the best. The problem is, as I already said, that 50% of human embryos do not continue division and the process of embryo evolution on day 4 or even on day 5 so it is not worth doing day 3 transfers because we cannot confirm that this is a viable embryo.
If using an egg donor, what is the expected number of eggs that will be collected?
So, if we do a normal stimulation, not a high dose stimulation, I would say something around 10 to 12 eggs but then we should focus on the number of mature eggs so in general between 8–12 mature eggs can be collected.
I want a two embryo transfer and I’m wondering if the clinic will do this if requested.
Of course, we cannot deny your desire for a two embryo transfer. We have an ethical committee just in case we need to discuss the convenience or not of an individual case but if you do not have any particular problem like maternal advanced age or two CS sections, etc., then, of course, we can accept the two embryo transfer after discussing with you why we always recommend the single embryo transfer.
What would you recommend if, for example, I have 2 embryos of really poor quality on day 3, would recommend to transfer them on day 3 or wait till day 5 although; however, probably there will be no embryos on day 5. So, will I end up without a transfer what are the ups and downs in such a situation? Is it to transfer embryos on day 3 or wait till day 5?
I really believe that it is better to go for blasto culture until you have two embryos on day 3 to leave them in culture until day 5. Then you will really check if you have at least one embryo to transfer of good quality, but if you do not have any embryo to transfer then you will not have the pregnancy. Then only you can understand why you would have had a failure. Many patients ask and they are worried about cancelling the transfers when leaving the embryos till day 5. But my concern is that it is very important to transfer only the appropriate embryos and not to just do embryo transfer because the most important thing is to have healthy babies and not to waste time on transfers that are not going to be successful.
How do you test the egg? Egg donor one, for example? I know the sperm can be checked by multiple tests.
First, before accepting the donors in the clinic, we do medical, psychological and genetic tests. Out of all the donors, we do not accept more than 20%. To begin with, we start with a gynaecological test and we ask the donors if they have had any problems regarding fertility if they have their own children. Then we do a personal interview and also we do ultrasound and hormone compile like AMH—I mean, the ultrasound and antral follicle count — to check that they have a normal ovarian reserve. Then we continue with serologies. Then we continue with a genetic test if needed, but of course, it’s after we have performed the stimulation that we can check the egg quality when they are in the laboratory. We can do this not only for donor eggs but also own eggs. The quality of the egg can only be studied because of the age so that’s the reason why we cannot accept egg donors aged 35 or more but the second possibility, the only other possibility, is to study the eggs directly in the laboratory.
What is the law in Spain regarding donor sperm? What about if the child is 18 years old and would like to meet his/her father? Is that possible?
I’m sorry but the Spanish law does not allow this. There would only be two situations when it would be acceptable to meet the father. This could be a medical reason. A medical reason if the baby needs a particular donation of the donor then this can be accepted but if not, it’s not possible.
Do you offer eggs from donors with proven fertility (donors who have already had their own children)?
Of course, we have donors with proven fertility and this can also be requested.
Does your clinic offer Skype consultation? If so, how much does it cost?
Yes, we do Skype consultation and for the moment it is free.
Do you offer family planning with egg donation? More embryos from the same donor to have more chances to have children from the same donor?
Yes, we do offer family planning. For instance, we have the possibility of having a guarantee of more than three blastocysts.
What information is the recipient given about the egg donor? Which team member is responsible for matching the egg donor and the recipient?
The information that Spanish law lets us give you is the age, the blood group and then if general characteristics are requested, we can offer the eye colour , hair colour, etc. General characteristics. Regarding matching the egg donor and the recipient, I understand that you are asking which member of our team is responsible for that. We have a coordinator of the egg donor and it is done by the gynaecologist him or herself.
What is the success rate of embryo adoption? If I want to choose this treatment, what should I consider?
Regarding the embryo adoption, it is around 45-50% pregnancy rate. What is more important is to consider also if you can ask for blastocyst stage because many embryos in our banks are day 2 or day 3 embryos so not all the clinics have blastocysts to do the embryo adoption.
How do we know that the embryos are of good quality or not in clinics without a time-lapse incubator?
Also in the traditional incubators before transferring day 5 or day 3 blastocyst the biologist needs to specify the category of that embryo. Then this should be recorded in the report and you should be informed about the quality of your embryo.
Do you recommend a clinic that guarantees only a specific number of mature eggs and not any blastocysts?
It is also an important aspect to consider but the most important is the guarantee of blastocysts because no matter the number of mature eggs that they are going to give you, sometimes there are donors that can respond with medication with more than 15 eggs and then the quality of these eggs and the quality of the embryos is low and they cannot achieve the blastocyst stage. So I would consider more the blastocysts guarantee than the number of mature eggs. The number of mature eggs is more a problem for the clinic but not for the patient. By contrast, your more important objective is to have blastocysts of good quality to transfer. Depending on your personal situation we would go for a one blastocyst guarantee or even two or three blastocysts guarantee but this is my recommendation.
Why do some of the embryos on day 5 that seemed to be good blastocysts with some fragmentation not make it to be transferred or frozen because they did not remove the fragmented material? Are these errors caused by low sperm quality, the egg or something else?
Good blastocysts that have a lot of fragmentation are not considered top blastocyst. Regarding fragmentation in the embryo development, it can be caused by either oocyte or sperm abnormalities so depending on the cycle results, we should recommend additional investigation if the donor sperm is used. It can also be a problem with the donor because of course, not all the donors achieve the highest qualities on the blastocyst stage.
Can your clinic assist in exporting semen from the UK if the husband is not able to travel to Spain?
Yes, we can help to organize such transport. There is no problem, if the husband cannot travel to our clinic we can of course export and do the treatment in our clinic.
We had a perfect embryo with egg donation transferred to a perfect endometrium, very good sperm quality and all the tests and hormones were OK. Nonetheless, it did not end in a pregnancy. What are the other options and where to look for the causes?
As I already said, if you had only one or two failures of perfect embryos on day 5 then we should focus on a three-dimensional study regarding the endometrium receptivity and also endometrium tests to study if there is a risk of infection inside the endometrium. Also, I would recommend the need to do a PGS to study the embryo before transferring and to confirm if it is an euploid embryo or not and the third point is to study other immunological and haematological systems that can interfere with the implantation.
What test do you do in the laboratory on the egg?
The problem is that we cannot do any tests in our laboratory or other laboratories before using that egg in the laboratory because if we test it, we cannot continue working with the egg because it’s going to die. We can only accumulate and continue if it’s mature or oocyte to continue with the process but we cannot do genetic tests directed to the oocyte because if we perform this kind of study, the egg cannot continue with the development.
If a child is born from egg donation and the child is diagnosed with genetic sickness, can we get more information from the donor if needed for the treatment of the child?
Yes, right, that’s what I’ve already said. We are one of the clinics that store DNA without a time limit. This is very important because in the future if your baby has a problem, then extra tests can be performed on your donor. This can give extra information to the doctors to check if this is a genetic disease coming from the donor or not.
I have had 8 own egg IVF cycles (one of those resulted in a positive, but ended in a missed miscarriage). I am now 43 and considering using donor eggs. Should I have any other tests before moving to egg donation? I have had ERA procedure, thrombophilia tests (no issues) and basic immune tests; an NK blood test, cytokines, etc. and no issues. Also no issues with sperm. DNA fragmentation was very low. Just wondered if I should have any other tests before spending money on a donor cycle.
It depends on your particular case. If the miscarriage happened when you were under 38 years old, I would study all the immunological factors that may lead to a miscarriage. But by contrast, if the miscarriage happened when you were over 38 years old, the main cause is the chromosomal abnormalities. I would not go for extra tests, and I think you can really go for the egg donation program.
What is the maximum number of guaranteed good quality blastocysts you offer from one donor? (this is for family planning)
Our highest guarantee is three blastocysts because we understand that in the case of the clinics that include guarantees with more blastocysts the problem is that you cannot guarantee it with the same donor. We understand that this is biology and we cannot guarantee more than three blastocysts so it is the minimum blastocysts guarantee. It can lead to four, five or six blastocysts but we do not work with higher blastocysts guarantees.
Did you say gynaecologist chooses the egg donor for the recipient?
Right, this is the gynaecologist here in our clinic who chooses the donor for the recipient. We ask our patients to fill in a form describing their characteristics. We also ask patients to send their photos because we have innovative technology to match your photo with a photo of the possible donors and this computer technology will give us the percentage of similarity between your face and the face of the donor. We use both systems, one where the gynaecologist chooses the donor and with this new application that can match your photographs.
I heard that the window when an embryo can attach to the uterus is a limited period. How do you calculate the optimal day or for transferring the blastocyst?
The majority of the patients have the window on day 5 to day 6. Usually, after 5-6 days of progesterone — so usually 5 days of progesterone we will go for the transfer but if we have 2 failures, then we perform an endometrium receptivity test to check if the window is perhaps on day 7 or even on day 4.
What are your thoughts on using acupuncture, Chinese herbs to support IVF cycle?
I understand that there have been some reports and some studies saying that acupuncture and extra treatments might increase the pregnancy rates. If the patient wishes to have this kind of treatment, I will recommend it. By contrast, I don’t have a particularly good feeling about the Chinese herbs because sometimes some of the herbs can lead to miscarriage. Yes to acupuncture and no to Chinese herbs.
Can I have a Skype consultation with you?
Yes, I guess you can go directly to the Egg Donation Friends platform and we will forward your request to the doctor and the team will get back to you. I will be happy to answer all specific questions by Skype. If you have any other questions, get in touch with us via email@example.com and we will be able to forward your questions to the clinic.
With 17 donor eggs, we ended up with 2 top-quality blastocysts. What is your opinion on this result and what recommendation would you give? Is it a standard result?
In general every three to four oocytes would achieve the blastocyst stage. For instance, in a normal stimulation with a standard donor response that can lead to, for instance, 9 eggs, we would get 2 or 3 blastocysts. In general in the donor program, if there are no extra problems like the sperm factor, then at least 75% of the blastocysts should be of good quality. I would say with 17 eggs it’s not a very good result if you get only 2 quality blastocyst. I cannot be 100% sure but perhaps this is not the highest quality of donor.
Would you recommend having an Endometrial Receptivity Test to find the best time for implantation? Do you also offer this?
Yes, we offer in our clinic these tests so you can just do it in a routine way—I mean before the first transfer—but what we do recommend after two failures you should do and check the endometrial receptivity. But, of course, we have patients who—no matter if they do not have failures— if they are going for their first-ever transfer, they really want to check the endometrial receptivity and of course we can do this procedure for them.
Do you use for donor matching only the photos and characteristics of the female recipient or also some characteristics of the male partner?
Yes, if the egg donor treatment is done for a couple, we take into account the characteristics of the recipient and also the male partner and in the case of two women, we do the matching based on both intended parents’ characteristics. But in accordance with our law, we should just take into account the female recipient characteristics. To be honest, I can only match you with the female recipients.
Is the ER test result good for the following cycles, does it always stay the same or does it show only the situation on the one tested cycle?
The data from this test shows that the response is similar in the consecutive cycles so if you do an endometrium receptivity test and the window is okay — which means that you can transfer on the same day. If you are undergoing estrogen hormone therapy, you just need to do it exactly the same way on the same days and with the same doses.
How much does the ER map cost?
I do not know the exact cost of the test but of course, my colleagues can answer your question. We will be able to check it for you. If you get in touch with us at firstname.lastname@example.org, we will forward your question to the clinic and get the answers.
Can the transfer be postponed to the day after, if the ER test is not good?
The endometrium receptivity test is to be performed in a cycle before doing the transfer. We will have the results and we will go in another cycle directly for the transfer so then we do not need to change our strategy. If the result of the biopsy says that the endometrium is receptive, then we can just do the same cycle and go for the transfer. By contrast, if the endometrium is not receptive, depending on how soon the window is, we should go for another biopsy before doing the transfer to be sure when we should transfer the embryo.
The Anti-Müllerian hormone, how important is that parameter for you in terms of deciding if a stimulation would make sense?
The Anti-Müllerian hormone is a predictor of quantity, not quality. It is most important and also you need to take into account the age of the woman so it’s not only the Anti-Müllerian but also the age that needs to be considered whether the stimulation is going to make sense or not. But I would say we cannot only take the Anti-Müllerian hormone into account.
I was told by a gynecologist that the endometrium receptivity test is only correct in the month that it is performed. Therefore he did not recommend it. What is your professional opinion on that? That was after two failures.
My professional opinion, which is based on literature and the research, is that we understand that if the endometrium is okay, when the biopsy is done in a hormone therapy replacement transfer, then we can truly understand that we can repeat this kind of treatment and we should understand that the endometrium is ok.
Do you consider the endometrium micro-inflammation a problem to be cured with antibiotics (10 days of doxycycline) or not? Some doctors cure it but others say that it has no influence on the implantation.
It is a very important issue to be considered. This and the possible infections in the endometrium. We should take into account this type of tests and decide if antibiotic therapy is needed. We also recommend it especially with miscarriages or implantation failure before another embryo transfer.
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