Dr Laura Garcia de Miguel, Medical Director at Clinica Tambre in Spain, is explaining the importance of communication between the IVF laboratory and the medical team during an IVF treatment.
Dr Garcia, in her presentation, covered the topic of the importance of communication between the laboratory and the medical team during an IVF treatment. Dr Garcia described in-house laboratories, the techniques used at the lab, which moment of your treatment you’ll coincide with the lab team, and the communication process between doctors and the team lab.
It’s crucial to remember that not all the centres have a lab in their clinics. Sometimes, the clinics use other laboratories. At Clinica Tambre, there are 2 laboratories, the andrology laboratory and the IVF laboratory. The embryologists on each team are specialized in the tasks they perform, and the laboratory director coordinates everything that is done. In the andrology laboratory, they perform spermiograms to check the general parameters and the quality of the sperm of each patient. At Clinica Tambre, Comet Fertility is used, which is a highly sensitive test, which allows for detecting both single and double chain DNA fragmentation. There is also a possibility to do the genetic matching for recessive mutations for every patient or donor, as well as the Chromsperm to check the genetic chromosome disorders in the sperm. Sperm freezing is also possible, and there is a sperm bank.
In the IVF laboratory, an oocyte retrieval procedure is performed, as well as oocyte preservation, there is also an in-house egg bank, and there is a possibility to do an ICSI procedure and Preimplantation Genetic Testing. There are also performed embryo transfers and vitrification of embryos.
Having in-house laboratories, as well as gamete banks, allows for faster and more efficient coverage of assisted reproduction treatments because communication with doctors, nurses and patient care is more fluid. The procedures are very well-defined, but at the same time, it is easier to personalize each treatment, approaching them from different perspectives, according to professionals from various branches of science.
The lab team is in charge of the RI Witness system, which is a security system included in the treatment without additional cost for the patients. It identifies each patient’s samples, and its use aims to avoid possible mistakes when manipulating or identifying the samples by using labels and individual identification cards. Before starting the process, the patients receive a card with personal data that is always used to verify their identity before obtaining a sample. Each tube plate or container is marked with electronic tags that are associated with the patient’s card. These labels and cards are read by RI Witness at each step of the process, confirming the identity of the patient at all times. This system has receivers that verify the data in each phase of the treatment and can detect any alteration in the protocol used to identify the samples and interrupt the process if necessary. Embryologists are also involved in embryo culture and the updates of its development every day. They will do the embryo transfer altogether with a gynaecologist, they perform the spermiograms. They have a significant role in gamete donation treatments.
Regarding seminograms, male patients will meet the andrology team when they come to the clinic for a seminogram where an interview will be conducted to be aware of factors that may affect the sperm, such as medication intake, some exercise, and fever. Afterwards, the sample is frozen, and the doctors discuss the diagnosis with the patient if required. At this point, it may be also necessary to talk to the andrology unit if there are any important abnormalities.
When it comes to embryo culture and updating its development, patients discuss their options with the doctor in choosing traditional (COOK) or time-lapse incubators (GERI). As soon as fertilization takes place, the laboratory staff updates the doctor on the evolution of the embryo and they call the patients to let them know if they have developed till day 1, 2, 3, or 5 days. If the embryos are going to be frozen or genetically tested on day 5, the patients are going to receive a call as well, otherwise, you will meet with the team and doctor in the operating room during the transfer. Before the actual transfer, the patient’s data will be confirmed, and again, the patients will be informed about the embryo quality and other characteristics.
Gamete donation treatment and donor selection is a very rigorous process in which most of the clinic’s team is involved. The doctors and nurses are dedicated to carrying out tests and seeing the patients at different appointments, psychologists complete interviews, and the laboratory team ensures the quality of the gametes. In addition, embryologists are in charge of performing genetic matching techniques between the recipient and the donor or both donors.
From patients’ or couples’ first visit with others, their case is analysed with the laboratory and asked for their opinion. The communication is either done in person, by email, telephone, in addition, every morning, there are clinical sessions, attended by embryologists, the medical team and patient care staff, where the next days of oocyte retrievals, embryo transfers and current cases are discussed. The whole team makes sure that all information and documentation are submitted.
Embryologists, like the rest of the team, have a fundamental rule in infertility clinics. Contrary to what some people may think, they have contact with the patients, they know who each person is, they know their names, and they know their medical history.
The communication between them and fertility specialists is crucial to thoroughly analyse which techniques and technologies will make patients fulfil their dream of having a baby.
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Yes, so my colleagues, the biologists call the patients every day to explain how the development of the embryos is working, they inform about the quality of the eggs and then embryos etc.
Before going ahead with the treatment, it’s always recommended to first come to the clinic, to see the atmosphere, talk with your gynaecologist directly and have the possibility to study the sperm and freeze a sample if everything is alright. At this point, it’s always the biologists that will share that information with your doctor, and we will confirm if the sperm is absolutely fine, to proceed with that. If it is a fresh sample, of course, the biologist will confirm before leaving the clinic that it’s a good sample and that we can go ahead with the ICSI or with the traditional IVF procedure. If there is any problem, we will share that information as soon as possible with you so if we require another sample, we will ask you.
We are always sharing the time-lapse video with all of our patients. All those embryos that are frozen or transferred, we’ll be happy to share that information with you and to be transparent and explain all the development of your embryos. Regarding the time-lapse system and all the information that is provided every day of the embryo development, it is the embryologist that will inform about it.
Regarding the indication, if it is necessary or not, it’s mainly the gynaecologist, the doctor that you’ll be talking to. When it comes to the PGD procedure, it is the embryologist.
When we’re doing the PGD the results could be absolutely normal, so they are called euploid embryos, and there are embryos with abnormal chromosomes, so they are called aneuploid embryos, and there is a grey zone called mosaicism. Regarding mosaic embryos those are a very various kind of embryos, so we really need to talk with our genetics experts to confirm if that mosaic, in particular, is possible to be transferred or not. Regarding mosaics, it’s very important to consider what chromosomes are involved, for instance, 21 chromosomes could not be transferred because it could be Down syndrome. If the geneticist is considering there is a low-risk mosaic in terms of having problems to that baby, we will talk with our patients, and if they don’t have a euploid embryo, we will recommend transferring it. Even though the implantation rates are lower and the miscarriage rate is a little bit higher, but we have ongoing pregnancies with mosaics embryos, so I encourage every woman, every couple if they don’t have euploid embryos to transfer the mosaic if it is a non-risk mosaic.
It depends on each case, what type of diagnostics. If it is a male factor, of course, we should go to ICSI, but it really depends and we’re a clinic that is always approaching cases very individually. We’re always talking with the embryologist before going ahead with the treatment, what type of technique they will be using on that particular couple or women. When we’re doing traditional IVF, we normally recommend that to do 100% if a woman, in particular, a couple has had a previous traditional IVF and has had good fertilization rates.
Embryologists have a different classification and different possibilities to identify the embryo, but usually, blastocysts that are considered very good would be a 4AA, which means that it’s really expanded. Regarding the letter A, it is referring to the inner cell mass (baby-making part) which is graded either A, B, or C and A is the best. In regards to the second A, it means the trophectoderm quality that makes the placenta and the membranes surrounding the baby, and again the best quality is the letter A.
So letters A and B are considered good classification, of course, A is the best, but B is also considered good embryos whereas C is really more intermediate and not that good. Grade D embryos are considered bad embryos, in terms of the possibilities of implanting.
Usually, the fertilization rate has more to do with egg quality than with sperm abnormalities or sperm quality, so only in very abnormal sperm like in teratozoospermia that would be the cause. There is no possibility to anticipate regarding fertilization because that’s something really considering egg quality and there isn’t any test to really confirm the quality of the eggs before the embryo transfer is done.
We always do the biopsy on day-5 of the embryo, so it’s always recommended to do it on day-5 embryos. To do the thawing and freezing again of embryos, it’s something that technically can be done, for instance, when we’re having frozen embryos on day-3 coming from other clinics, we do the thawing, and we leave them to day-5, and if we have supplementary embryos apart from the good blastocyst to transfer, we will freeze again. We have many children born after these techniques of thawing and freezing again. But, if it is thawing and freezing again because we want to do PGT-a, it’s not indicated because then the quality of that embryo, the possibility of implantation will be decreased.
All invasive procedures will not be positive for the embryo, and supplementary embryos need to be frozen because they will have potential success rates, and if by any reason there is an embryo that should be defrosted again, we can have some possibilities in the future. It’s absolutely fine, so the best approach for PGD is to create embryos and every time embryos achieve day-5, to do the biopsy, and not to do egg banking or embryo banking, and then thawing and freezing again, that’s not the best approach. Sometimes clinics are doing this because of financial issues, but the best for your treatment is to do egg retrieval.
It’s something that when you have a low ovarian reserve, it’s possible, so we need to try to maximize possibilities to have more eggs and more embryos but otherwise, we have other possibilities, for instance, luteal phase and to do two cycles in the same month and having perhaps two embryos to do the freezing but every time the embryo achieves day-5, it’s better to do the biopsy. If the age is over 41, I would definitely recommend PGD, even having one embryo. But if there is only one embryo and the age is lower, then I would recommend not to do the genetic screening because as long as there is only one embryo and we have said that it could affect that embryo negatively. When only having one, perhaps I would consider talking with that patient in particular, if the patient is accepting the risk of transferring without PGD in order to try to minimize the impact on that embryo.
The best approach is to try to have a maximum number of eggs for that patient in particular. So we need usually high dosage, we need to try to consider if LH is necessary or not and depending on the previous protocols, we need to see if double trigger with a double shot to have more metaphase eggs is necessary or not. Then depending on the number of eggs and everything, we will recommend doing the luteal chase and having two stimulation, so the double stimulation to maximize possibilities or have more embryos.
We know that the high dosage of gonadotropins when we are considering the maximum of 300 or 400 units, it’s not affecting the embryo development negatively. It has more to do with egg quality, so we can only accept this situation when we’re having more than 23-30 eggs. By contrast, when during the egg retrieval we have less than this number, the embryo quality will not be affected.
Normally, the limit for general laboratories is 30 ng/mL, so it’s recommended to have a minimum of 30. If it is less, we need to give supplements of vitamin D.
Not at all, because these are two absolutely different things, so melatonin is a hormone that we do create every day, but we can recommend taking vitamins with melatonin to increase antioxidants and to increase egg quality. Aspirin, it’s absolutely different, it’s a medication, and it is involved in other paths.
For a low-ovarian-reserve patient, there are two approaches the mild IVF or normal IVF with more important dosage so we should consider how you’re dealing in your previous cycles. Normally, I do not prefer doing the mild IVF because if that person, in particular, can have 2 eggs instead of 1, it’s really doubling the possibilities. If one patient is having 10 or 11 eggs, this is not a big difference, but if we’re having 1or 2 eggs, it’s absolutely different.
