Egg donation program: clear benefits and hidden risks

Diana Obidniak, MD
Fertility Specialist, Head of ART of Birth Clinic, ART of Birth Clinic

From this video you will find out:

Recommendations for egg donation IVF
Egg donor qualification
Benefits of egg donation IVF
Prevalence of aneuploidy and morphology evaluation of embryos
Endometrium as a biosensor of an embryo quality
Morphological alterations of endometriosis
Chronic endometriosis
Functional alternations: compromised window implantation

Egg donation program: clear benefits and hidden risks

Pros and cons of egg donation IVF programme

Dr Diana Obidniak, Head of International Cooperation Department at AVA-Peter, an affiliated professor at St. Petersburg State University, also a practising fertility specialist talked about the pros and cons of egg donation IVF programs. Dr Obidniak specializes in so-called difficult patients diagnosed with recurrent implantation failure, repeated pregnancy loss, diminished ovarian reserve, where there is no way to do IVF cycles with their own eggs.

Egg donation – when is it recommended?

When we talk about the egg donation program, there are certain circumstances when we are pushing patients for this program. The aim is to minimize their time to pregnancy. Patients of advanced reproductive age are usually the ones where egg donation will be recommended. However, the age limit is going up, about 10 years ago, all the guidelines said that women over 39-40 years old were recommended to try egg donation programs. Nowadays, it’s always the second line of therapy. We have experience with embryo banking, there are different types of ovarian stimulation, so in many cases, we can manage to get good embryos with own eggs. Unfortunately, when the woman’s resources are already exhausted, we have to implement a donation program and make it very delicately. Egg donation programs are also recommended for women with ovarian failure due to menopause, premature ovarian failure or ovarian surgery, for example, in patients with severe forms of endometriosis. We can expect that after surgery, the volume of ovarian tissue may diminish, that’s why, unfortunately, in some cases, we have to recommend an egg donation program. There is also a need for egg donation in patients with recurrent pregnancy loss or the inability to obtain euploid embryos.

Egg donor – selection process

Concerning the donor selection, you will find rather similar descriptions. In any clinic, this program aim is to be effective but also very pleasant for the patient. The main thing is to get a healthy baby. At Ava-Peter clinic, only young and attractive women under 30 years old with their own healthy babies are considered. Ava-Peter clinic has the largest database of donors and vitrified oocytes in Russia. There are European and Asian phenotypes available. All donors undergo genetic testing on common heritage diseases. We try to provide as much information as we can about the donor, such as the donor’s appearance, medical background, education, hobbies. The questionnaire consists of more than 70 questions. A special department of managers is always in touch with the donors to be sure that everything goes well. There is no waiting list, there are both so-called vitrified eggs in the database, and there is also a list of donors who are ready to initiate the treatment at your earliest convenience. Regarding the selection process of the donor, at first, there is a general interview. Donors are asked why they want to be involved in such a program. After that, genetic testing, such as Karyotype, is performed. Screening of so-called monogenic diseases is also performed. Those are rare diseases, and it results only when both parents are a career of these monogenic diseases. They are considered rare diseases, but unfortunately, if the clinic doesn’t provide such screening, it can lead to dramatic results even in the egg donation program. When we are sure that the candidate is suitable and healthy, in terms of genetic competence to be involved in the egg donation program, we initiate a gynaecological examination and a general physical examination. We always assess hormonal levels, screen for infections and perform an ultrasound. We do it several times because if the donor is involved several times, we repeat all those examinations, each time, before initiating the program. When we talk about young women who already have their own babies, it’s not a guarantee that the quality of eggs will be good. That’s why we have implemented so-called trial ovarian stimulation following trial fertilization with a sperm donor. That way, we can get information on how the donor reacts to the simulation, what quality of eggs we can expect, what number of eggs we can expect, etc. It is a strict selection process, not more than 20 or 25% of applicants are approved.

Egg donation – clear benefits

The benefits of egg donation programs are for sure high success rates. Success rates differ in different clinics, different countries, for example, at Ava-Peter clinic, it is from 65% to 70% depending on the quality of sperm and presence of concomitant diseases in a couple. When we talk about success rates, we mean clinical pregnancy rate, we are not talking about fertilization rate or the number of embryos we obtain. The main aim is to make you pregnant. Nowadays, such programs are highly effective, but we also need to assess the time to achieve a pregnancy. That’s sometimes the basis for a recommendation because when we talk about patients of advanced reproductive age or with minimal ovarian reserve, we always discuss alternatives. We can offer embryo banking programs, but that will take, for example, 6 or 7 months till we can start the embryo transfer. There is also a risk that some or all embryos will be abnormal, so after those 6 months, we may have to go with the egg donation program anyway. If we start with an egg donation program, we can minimize the time for pregnancy. This will also minimize financial expenses. All the physicians, all over the world, are recommended to take into account not only effectiveness and medical issues but also the cost and expenses the patient will take.

Egg donation – hidden risks

Egg donation is considered to be an effective tool in creating competent embryos. Is it applicable for all cases? Even when we’re talking about young women, and we obtain a good quality of embryos, we should expect that a great per cent among these good-looking embryos will be abnormal. We have so-called 4 types of embryo quality according to morphological qualification. We assess it by their external appearance and then what type of quality we see. We usually divide them into excellent, good, average and poor. In your medical report, you probably have seen some figures and letters, for example, 4AA, 3 BB, and it is precisely the mode of assessment of the embryos by their external appearance. Unfortunately, this way of embryo assessment doesn’t provide objective information about their genetic competence. One of the trails shown on the slide has demonstrated that there is a bad correlation between the quality of embryos by their external appearance and their genetic competence. When we are talking about excellent embryos, the prevalence of abnormal embryos among this category of embryos will be close to 40%, it’s a very high rate. In poor embryos, we will find only 25% of normal embryos, so more than 75% would be abnormal. That’s why, some time ago, we have tried to implement pre-implementation genetic testing even in egg donation programs. Several years ago, it was a very common opinion among fertility specialists that the egg donation program is so effective that there is no need to add more technologies. However, according to our empiric experience, we have started to implement this practice, and we have represented our own results showing that:

For sure, the prevalence of abnormal embryos is lower than in the general population because the donors undergo a very strict selection, they are already approved by genetic mode of investigation. There is a recent investigation called ‘Major factors involving an implantation rate of PGT-A euploid embryos in egg donation program over 35 years where they divided all the patients into two groups. Group A consisted of 188 egg donation programs with PGT, and group B consisted of 58 egg donation programs without PGT. They wanted to compare their outcomes of clinical pregnancy rate and live birth rate. In group A, the implantation rate had much better results. In a group where an egg donation program was performed with pre-implantation genetic testing, the implantation rate was 46%, and in group B without pre-implantation genetic testing, the implantation rate was 20%, which is not a very high result.

In many clinics, you might observe a 46% of implantation rate in the program without pre-implantation genetic testing. It is important to look at that great difference because the technology used was the same, physicians were the same, their achievement to the patient was just the same, but the results are very different. Dr Obidniak emphasized that when we are talking about egg donation programs, we usually use the biological material of the partner or husband, the quality of sperm also plays a crucial role in this process. One of the trials was called: Evaluation of the impact of quality of sperm morphology on the rate of aneuploidy rates in donor oocyte program. We already have data that proves that in all programs, a male factor will have an impact. If we have severe male factors, we should expect that the outcomes will be worse even in the egg donation program. There was a significant difference between the groups with different sperm quality, so these results suggested that diminished sperm quality is correlated with the aneuploidy rate in pre-implantation embryos. The author has observed total aneuploidy, trisomy, monosomy, severe defects in the embryos.

Embryos – good clinical practice

By good clinical practice, we mean performing pre-implantation genetic testing and selective transfer of one embryo. Why is it so significant? We have started to do the selective transfer of one embryo several years ago, and physicians of the so-called ‘old school’ of reproductive medicine were worried because usually, they wanted to transfer 2 embryos. It’s associated with vitrification technology (freezing the embryos), and back then, we hadn’t had such a great and safe technology of freezing the embryos. The physicians were not sure that this freezing method would not have a bad impact on the quality of embryos. That’s why they didn’t want to use vitrified embryos. Nowadays, vitrification, also called ultra-quick freezing of the embryos is safe, you can be sure that it will have no risk of defreezing. There is never 100% of positive results, but it’s close to 99%, so you shouldn’t be afraid of freezing the embryos.

The importance of implantation

The main goal in this whole process is to make sure you’ll be able to take your healthy baby home. However, a good embryo is not a guarantee of pregnancy. The very beginning of your pregnancy is the process of delicate interaction between the embryo and the endometrium, and it is called implantation. For many years, it was thought that in this process, there were just two main players – embryo and endometrium. Around 20 years ago, a team of investigators, among them Benkhalifa, demonstrated there are more players such as cumulus cells, sells, microenvironment and various growth factors which play an important role, contributing or hindering successful nidation. When we talk about IVF success, we always should assess all other factors, even in patients who had ineffective IVF because of bad quality of eggs or advanced reproductive age and where an egg donation program could be the solution. The main players are embryo, endometrium and also concomitant pathology. We know that, for example, thyroid function has a great impact on the initiation of pregnancy and progression of pregnancy. We should assess all these features. In every egg donation program, the endometrium is a very significant player because it is a natural biosensor of embryo quality. It has such a fragile balance between their capability to accept the embryo, we call it receptivity, and the capability to block the embryo implantation, so it’s called selectivity. This balance can be altered by functional and morphological alterations. When we are talking about morphological alterations is one of the most common defects which we observe. We take into account:

inflammatory process (chronic endometriosis)
hyperplastic processes (polyps or micro polyps)
intrauterine synechiae (adhesions between the layers of uterine)

The endometrium is the internal layer of your uterus, it carries your uterus inside. The cavity of your uterus can be considered as an apartment for your future baby. If those conditions do not seem very optimal or proper for the embryo, the implantation will not occur. We may also observe so-called biochemical pregnancy when this interaction between embryo and endometrium has started but then were interrupted at the very early stage.

Chronic endometritis

Chronic endometritis is the condition involving the breakdown of the peaceful coexistence between microorganisms and the host, immune system in the endometrium, resulting in a special type of chronic inflammation in the endometrium, characterized by non-apparent clinical signs. The clinical signs of chronic endometritis are very latent, in most cases, you will pay no attention to them, for example, the characteristics of your menstrual bleeding can be a little bit altered. During your menstrual bleeding, you may notice some brownish bleedings. However, most women do not pay attention to that, and nobody sees these signs except the woman. That is why it is crucial to listen to your organism, you should be open with your physician and tell them about anything you’re worried about. The prevalence of chronic endometritis differs very much. In the general population, it is present in about 10%. Patients with several ineffective IVF attempts or recurrent implantation failure or especially in repeated pregnancy loss, this rate can go up to 66%, which is very high. When we see a patient with a dramatic history of several ineffective IVF attempts, we always check the endometrium, especially if there was a history of several ineffective egg donation programs, because we see such patients all over the world. Another thing is functional alterations: compromised implantation window. It can play a great clinical impact, and generally, it’s the basic knowledge about our physiology. It’s not that implantation is just the delicate dialogue between embryo and endometrium, this dialogue should also be synchronized. The synchronization of the processes of embryo development and the maximal endometrial receptivity is necessary. In the egg donation program, we already have the embryo developed till the stage of the blastocyst. In 65% of women, this stage of the blastocyst, in natural life, will be synchronized on the 6th day of producing progesterone inside the body. In many protocols, especially in our traditional understanding of endometrium preparation, it is recommended to place the embryo into the uterus after 5 days of administration of progesterone. However, actual data demonstrates that it’s just about 65%, it’s not that much if we talk about woman’s happiness. Unfortunately, we have patients with ineffective egg donation programs in different clinics with good embryo quality.

ERA and BeReady tests

Nowadays, we have two tests called the ERA test and BeReady test, which will help us identify the right time to perform an embryo transfer. It requires doing a biopsy of your endometrium and assessing their expressions of a panel of genes to be sure that we know their proper time to perform a personalized embryo transfer. On the slide shown, the investigators have compared several groups of patients, all the groups were standardized by age, BMI, the number of embryos per embryo transfer, they have compared frozen embryo transfer, fresh embryo transfer and personalized embryo transfer. Comparing the two groups, frozen and fresh embryo transfer, we see the result is high, it’s close to 60%. However, in a group of personalized embryo transfer, the rate of clinical pregnancy was 85.7%, which is very high. On the slide shown, there are some samples of results of the BeReady test analysis report. The green area means the endometrium is receptive, and if we see a low score, it means the endometrium is pre-receptive. If we have a high score, it means that the endometrium is already post- receptive. Sometimes if there is a very high displacement for this window of implantation, we have to repeat these results. In most cases, one examination provides enough information to enhance your outcomes.

Case report

The woman was 44 years old, she had 9 embryo transfers in her medical history. She had 4 embryo transfers performed with her own oocytes and 5 with the egg donation program. She started her treatment 10 years before her application to Ava-Peter clinic. She had a rather difficult medical history, she had severe endometriosis, chronic endometritis with severe activity and autoimmune components. We suggested an egg donation program following pre-implantation genetic testing, her husband’s sperm quality was also bad because of the age, and there was some concomitant pathology. We implemented pre-implantation genetic testing (PGT-A), and among 6 embryos, we observed that just 2 of these embryos were good. When we were sure that we have enough embryos, we started to prepare the uterus for embryo transfer. We performed a hysteroscopy, her uterus was covered by micro polyps. Unfortunately, it’s not that easy to detect these micro polyps by routine ultrasound, and that’s why she wasn’t aware that she has some problems with her endometrium. We removed all those micro-polyps, after that, we performed delayed frozen embryo transfer in a natural cycle because, despite the age, she had a rather regular menstrual cycle. If we can implement embryo transfer with no additional hormones, we usually try to minimize our intervention and make it a natural cycle. As she also had an autoimmune component, we recommended PRP therapy, it’s so-called Platelet Rich Plasma, this plasma has great antibacterial activity and also it contains many growth factors which make a very delicate recovery of natural resources of the endometrium. We have obtained clinical pregnancy, we transferred just 1 embryo, the delivery was performed naturally, without a cesarean section.

Take-home message

I believe that implantation is a: Symphony Orchestra. It doesn’t matter if it’s an egg donation program, conventional IVF cycle or surrogacy program, that doesn’t change it. Also, an egg donation program is an effective solution only in the context of receiving a competent embryo. Sometimes, there are indications for pre-implantation genetic testing and its implementation in egg donation programs, and in my mind, good clinical practice in the reproductive field requires attentive assessment of all factors which can have an impact on the implantation process.

Pros and cons of egg donation IVF programme - Questions and Answers

Does egg donation cover bi-racial couples?

It is definitely possible. There is no difference for sure. It doesn’t play any significance.

I want to ask if is there any African donors or Indian donors?

Unfortunately, we don’t have donors from Africa or India, it is very hard to find such donors in Russia.

Would you offer multiple transfers? Is there a difference in the price for multiple egg transfers?

I would like to clarify what you mean about multiple transfers, it’s never a difference in price, but it doesn’t make sense for medical issues. Our aim is to get one pregnancy, one delivery. Ideally, if it’s one embryo transfer we want one pregnancy with one child because multiple pregnancies provoke many risks associated with OB.-GYN practice, not with IVF cycle. Multiple pregnancies cause a greater risk of some problems with health or babies, that’s why we have implemented selective embryo transfer, which doesn’t play a bad impact on the success rate because it’s quite the same. The percentage of twins is much lower, it’s just minimal, and so consequently there are very few complications during the pregnancy. We do not recommend it, we can do it technically, but we don’t do it because it’s evident that it will be bad and not a good thing. It can provide harm to your organism.

After many failed own egg transfers what is the average number of transfers to succeed with egg donor for healthy 38 y/o recipient with unexplained implantation failures?

To tell you the truth, there is no correlation between the number of IVF cycles with your own eggs because we expect that using egg donation as a solution because egg donation will prevent the course of your previous implantation failures. That’s why we should expect that if the donor is good, and we expect that all clinics share responsibility and improve the quality of their egg donors. If your physician pays much attention to the other factors, you can call it pathology to the endometrium, and if there are some defects in sperm of your husband, it’s better to implement pre-implantation genetic testing so for sure if we pay attention to all the factors, we expect to have a pregnancy from the first attempt. In any situation, our aim is to shorten your time to pregnancy and do one but successful IVF cycle especially when we talk about egg donation program.

What is the maximum age for IVF in your clinic Ava-Peter?

It is 50 years old.

Do you do egg donation for over 50?

Unfortunately, it is restricted but we should take into the account that it is restricted, not in terms of the law system but also according to all the medical recommendations, according to a World Health Organization, the reproductive age for a woman is under 50 years old. After that, we can discuss the implementation of an examination program only if we talk about surrogacy program, also because it’s just not safe to bring the pregnancy after 50 years old. It’s very risky, and it’s a great stress for the organism, that’s why we should be sure that your health and your organism is ready for this. Unfortunately, over 50 years old it’s very risky so you can consider egg donation cycle with examination only in the context of the surrogacy program.

The success rate is based on a take-home baby?

The success rate of 65-70% is the clinical pregnancy rate, but as we make a selective embryo transfer and we implement in most cases pre-implantation genetic testing, the miscarriage rate is very low, so it’s not more than 8%, it’s considered to be very low. We have great statistics, and the live-birth rate is more than 55%.

Are there cases that egg donation doesn’t work at all after trying many times because of unexplained implantation failures, and they have to turn to surrogacy? How often does this happen?

Surrogacy is maybe even the third line of our recommendations. Only when we have understood that there is no opportunity for women to bring the pregnancy herself. I would like to share my opinion, which is rather common for many experts that unexplained implantation failure is in most cases just the lack of tests provided. In many cases, it’s just associated with not performing tests of implantation window, not great quality of hysteroscopy provided. Unexplained implantation failure usually it’s just the diagnosis which is a diagnosis of our desperation, that we have by this moment no evidence-based tools to verify the reason for your problem. For sure for us, it’s also a problem, in many cases, if we talk about surrogacy program usually we have the certain diagnosis, which can be associated with the competence of uterus or there can be contraindications for childbearing. For example, there is a heart disease or lung disease or autoimmune problems or kidney problems because our centre is affiliated with the centre treating the disease of kidneys and treating the disease of intestines, so we work with rather difficult patients. That’s why we have extensive experience of a surrogacy program, but it’s not such a common thing to move to surrogacy because we have unexplained implantation failure, we move to the surrogacy only when we understand that there is a great problem with the uterus, which cannot be fixed by this time, at this stage of development of medicine. To tell you the truth, it’s a very rare situation when we talk about unexplained implantation failure, I can’t even remember when we moved to surrogacy because of unexplained implantation failure. We always try to find the reason and fix it, so usually, we find the reason.

Do have like a take-home baby guarantee?

Yes, we have for such a program. We guarantee that if after three embryo transfers, the pregnancy is not achieved, you can take your money back, you can take the refund of 50%, or you can continue your treatment till the pregnancy comes without additional expenses. We have such program, they are rather popular to tell you the truth because for sure patients need this information that we share the responsibility, not only providing emotional support and being in touch and just doing our best but also in terms of financial relationships between the clinic and the patients.

The borders are closed. My frozen donor sperm is in another country where I will go ahead with egg frozen donation. Should I start now, as I’m not needed to be there to create the embryos – they have sperm, and they have my donor. They could freeze the embryos and wait for me while going with PGS. This way, I would have a clear situation when the borders are opened, and I could travel for a transfer saving the waiting time. Is this risky to freeze and unfreeze it this way?

For sure, it depends on the country but nowadays, the European Society of Human Reproduction and Embryology and American and Russian Society for Reproductive Medicine have established the protocol of safe practice especially if we are talking about both vitrified egg donor and sperm donor, so if the clinic follows this strict, standardized protocol, it is considered to be very healthy, but for sure it’s better to ask this question your physician who knows the internal information in this clinic and I can talk to you sincerely about the situation in the country. If we’re talking about Russia we perform such cycles when we do not mean that the patient will come to the clinic, so if we start cycles, we only mean that we will do a freeze all cycle, so we will not make any embryo transfers, and we are freezing the embryos. According to the available data, there is a minimal risk of making the embryo cells infected. It’s considered to be rather safe, but it’s better to discuss with your local physician.

Is a donation non- anonymous or do we have a way of requesting it individually to any donor? Do we have access to their appearance as an adult, even if only showing to us and not handling it via mail?

In Russia, the donation is generally anonymous, but it means that the donor can provide their pictures if she is ready so our base of donors consists of donors who are ready to share their Picture. They are ready to make a video call with intended parents, some of them are ready to meet you but if we talk about disclosure of their personality f.e.20 years later, after your baby grows up, unfortunately in Russia it’s not ethically approved, so we cannot guarantee that 20 years later the donor will be ready to meet your baby, but we have all the details of all the information concerning the donor, and we are still in touch with them but now what we can provide are the pictures of the donor, we can make an appointment for the meeting if you want, we can schedule a video call and provide many other opportunities. The manager will ask you about what features are significant for you, what do you expect from the donor and then send you the profiles of the donor which can match your preferences. The database is very large and is rather dynamic by this moment we have limited access to the electronic database so the managers can send their portfolios for you via email for sure.

What is the age limit of your donors?

We do not consider the donors over 32 years old Usually, the average age is 25 – 28 years old but not more than 32.

I put on weight-average 4 kilos with every transfer. Would you recommend to loose before trying again? I’m 171cm and 78 kg. If I get pregnant now – could it be too risky to gain pregnancy weight and be around 100kg while pregnant?

Unfortunately, maybe the intervention, the medical prescription was a little bit tougher than it should be in your case, as you are gaining weight after every transfer. You should do a consultation or provide your hormonal test and discuss it with endocrinologists or with the fertility specialist. If your specialist has such competence but for sure in any situation, if we have a problem we should find the reason why you have this problem just after that. We can make an individualized treatment plan. In your situation for sure, it’s also an abnormal reaction to this fertility treatment maybe it’s associated with emotional unsatisfaction because of that result, maybe it’s the result of some abnormalities after hormonal medication. So to answer your question, for sure, it’s better to lose some weight, it’s comfortable for you, that’s why it’s better to verify the reason why you had started putting on weight. Try to fix this problem before transfer.

How do you calculate the implantation window in an artificial cycle, as it is not necessarily linked to the endometrium thickness only?

The implantation or window is identified with these two methods we have mentioned previously, so-called ERA test and BeReady test, so both methods require remodelling of an artificial cycle or natural cycle. We just make the same preparation of the endometrium as we are planning to do during the embryo transfer cycle and just at the day when we would do the embryo transfer, we are taking the biopsy from the endometrium, and then according to the genetic testing, we analyze the expression of the genes and then I have the conclusion what time if there is a replacement of an implantation window, so there is no correlation with an endometrial thickness between implantation window and the thickness. For sure, the thickness of the endometrium also plays an important role, there are data, and it’s already well known that we need at least seven millimetres for successful embryo transfer.

Does blood type matter with egg donation?

If we talk about enhancing the result for sure not. We always try to find the egg donor with the same blood type as the woman has or her partner has. It’s not associated with good or bad outcomes, it’s just in case the couple doesn’t want to disclose their status to everybody. Just to prevent the risk of disclosure this information for some reasons, the baby can have indications for example for blood tests, and if there will be different blood types with the parents for sure it would be Rather obvious that egg donation program was implemented, so we just want to prevent such social risks.

How likely is chronic endometritis in a case where there have been 3 failed embryo transfers? After how many does it start to become a major concern? Also, can this be tested before treatment begins?

As we have mentioned during the presentation recurrent implantation failure and if unfortunately, you have 3 failed embryo transfers for sure it’s considered to be recurrent implantation failure. The chances of finding chronic endometritis also depend on the quality of the embryos. If the quality of embryos was good according to their available data, the prevalence of chronic endometritis will be close to 60%. If the embryo was not so good their prevalence will be lower but still very high close to 45%. After 3 failed embryo transfers, according to all the guidelines and according to the experience, I should recommend you to pay attention and to do proactive diagnosis of the status of your endometrium. So the golden standard of evaluation of the endometrium is hysteroscopy, which is the method of visualization when we insert a thin camera into your uterus, so it’s minimally invasive, but by inserting the camera inside the uterus we can assess the status of the endometrium. In the golden standard, we also can perform the first stage of the treatment, so if we see some polyps because sometimes the location of polyps doesn’t allow to notice them by ultrasound. That’s why hysteroscopy gives much more objective information, but during hysteroscopy, we can not only detect the pathology, but we can also start to fix this problem and initiate the surgical stage of the treatment.

I have endometriosis, and my doctor said I might have an issue with my immune system. Do you recommend any treatment before a transfer, when a woman has endometriosis? Any injection of cortisone, etc.?

There are approved protocols when the treatment of endometriosis should be combined. I would like to have more information on how the endometriosis was verified in your case. To make a certain diagnosis, it is important to know if there were any surgeries like laparoscopy or hysteroscopy or it was a suggestion by ultrasound. The quality of your eggs is not the basis to have the diagnosis of endometriosis, there should be at least several ultrasounds performed. If we are talking about endometriosis of uterus, or about the endometriosis, a so-called external genital disease, endometriosis in ovaries or your abdomen, we cannot see it by ultrasound or by egg quality, we can make a suggestion, but we have to prove it, at least make blood tests called CA125, it’s a blood test, it’s better to make it twice during one menstrual cycle, one time during your menstrual bleeding and the second time during the middle phase of when we can expect the ovulation. If you have endometriosis, no doubt you need to have treatment. At this moment we have approved tools, they are Rather easy for intake, so first-line treatment is the pills, which you have to take once a day at the same time constantly, for at least three months. Endometriosis requires to be staged because there are four stages and the tactics, that treatment plan will differ depending on the stage of the disease. If you have endometriosis, it’s better to be examined. When it comes to treatment, we don’t talk about cortisol or injection. Endometriosis has autoimmune nature, but that pathogenic treatment is not associated with injections of cortisol in the treatment. At this moment you haven’t had the diagnosis yet, you have for the uh suspicion that you may have endometriosis, but it’s better to prove it and do treatment prescriptions only after verification of this diagnosis.

Do you recommend frozen egg donors over fresh during this pandemic?

I recommend doing everything safely. At this moment, we have a standardized protocol on how to act during the pandemic. It is the same protocol in all the countries, the indications and the tools of prevention of the risks are the same. I bet that even Rusing fresh donors are the safe option when it is allowed because if it’s not safe, your clinic, your physician will never recommend it or will never make this possible to do. We already have a protocol to perform fresh cycles, and I know that in some countries, they have already started to do a simulation of the donors. In Russia, at this point, we do not do any ovarian stimulation, neither for donors nor for patients but we expect that we will start it not later than in a month because in two weeks we expect, that it will be totally safe, so we will wait a bit more. I expect, that in other countries it can be already safe because the process was a little bit earlier so in those countries the process is already at the stage of recovery. I’m sure that you should ask this question to your physician at your clinic. I bet that he will answer very sincerely because each physician wants just to make nothing but good.

Does your clinic (Ava-Peter) generally perform other tests as standard e.g. pelvic exams, fibroid detection, etc. to see if there are factors that may affect the reception of an egg?

It’s just the normal, standardized form for everybody, so we have recommendations from the medical committee in Russia, Medical Society for Reproductive Medicine, so we need to do all the examination you have mentioned, in each situation. The pregnancy is a very long journey so we should be sure that it’s safe to do the embryo transfer. That your uterus is capable of bringing the baby, there are no defects in different organs, that it can get worse during the pregnancy because pregnancy is a stress for the whole organism. It’s a physiological process, but it’s still great stress for the organism, that’s why you should be in good form. No person is in perfect form, for pregnancy but some of such problems can be treated before as some of the problems can be treated even during the IVF cycles, but some of them can be risky and can be considered as a contraindication for IVF or for carrying a pregnancy. We should assess it before planning treatment for the patient.

What is my chance of getting pregnant with my own egg at 44 y/o with an AMH 0.2 FSH 35?

Unfortunately, I should tell you that the chance of having a successful program with your own egg is not high for sure, and it is not associated with your AMH but is mostly associated with your age because we know that there is a strong correlation between the prevalence of abnormal embryos in population and the age of women after 35 years old, the general risk of abnormal embryos increases. After 39 years old we see an extreme elevation of such risk and we see that about 80% of the embryos will be abnormal among those, which reach the stage of the blastocyst. Unfortunately, not many women after 33 years old produce eggs which can develop till the stage of the blastocyst. We obtain the eggs, there is no doubt because we have 19 modes of ovarian stimulation, so we have a lot of feasible methods of deletion of your treatment, so we will obtain the eggs, but unfortunately the quality of those eggs will be very bad just because of the age. We have to tell the truth, I had a woman who had her own baby with her own eggs at the age of 48. It’s the record in our clinic, but she should be considered as an exclusion. You have provided FSH and AMH which demonstrates very physiological changes, so you have normal physiology of a woman. Unfortunately, we expect that the quality of embryos will be very bad that there is a great risk that we will have no normal embryo for embryo transfer.

Due to the fact, the borders are closed, would it be possible that you ship the frozen eggs from your database to another country, where I can enter and where egg donation is allowed?

Yes, for sure, we have even our own shipping company, but I think that during the following months, it will be just impossible to do the shipping because I think that in the following one or two months, all the countries will be a bit worried of some transportations or some active movements. If you’re ready to wait for a month, it’s okay, but I’m not sure that we can manage to do this shopping during the following months.

Do you do the ERA or BeReady test in your own clinic (Ava-Peter)? Or send it to another lab/ country?

We perform ERA test in Russia, and BeReady test, we send to Estonia. It’s very close to St. Petersburg, so it’s not a problem, but BeReady test is cheaper, so it’s more affordable, even with including the expenses for shipping to Estonia. Their effectiveness and their objectiveness all the data are comparable, it is comparable, that’s why we always discuss with the patients those two alternatives because in terms of effectiveness and providing reliable data they both are good. Sometimes if it can be made cheaper for sure, we want to minimize financial expenses.

With DNA test, and egg donor, will the child DNA be the same as that of the couple?

Well, the child will have DNA from the husband if we use an egg donor. The child will have DNA from your partner or your husband, so there will be no genetic connection between a woman and the child. Actual data provides certain information that a woman during the pregnancy has like a trophic function for the baby, so her blood circulates also inside the embryo. It provokes, and it regulates all the expression of all the genes, that’s why even by appearance, even by the character, the child will be very similar to the woman, though genetically there will be no connection.

I had hysteroscopy recently, and the doctor removed the polyps. Was that a sign of endometritis? How long until they will possibly come back – if there is this possibility?

We can verify endometritis using so-called immunohistochemistry by detecting CD 138 or CD56. It requires special staining of the samples for the endometrium. If the doctor has removed the polyps, it’s a sign that you had chronic endometritis but removing the polyps is just the first stage of treatment. You have to prolong the treatment using medications, what kind of medications, usually it is identified depending on the pattern which was observed during the hysteroscopy. According to the conclusion from pathology, we should assess not only the morphological process but also accept the activity of inflammation. If the inflammation is rather active, if there is a need for antibacterial therapy, sometimes there are also in some mode micro polyps in other areas of the uterus. There are connections, adhesions, they can be very slight, but we still need to implement some ferment activity or PRP therapy. You have to complete the therapy, as prevention of regression of endometritis and the polyps. Unfortunately, I cannot give you just the standard protocol because we are stating that the treatment should be individualized and should be evidence-based. The presence of polyps doesn’t provide enough information concerning the activity of the process and the stage of the process, that’s why I just can recommend having a complete therapy to prevent the residue.

I am afraid my lining will not grow (for egg donation transfer) as I am no longer having regular periods, and it is normally 6.5mm. Is there anything rather than oestrogen that can be prescribed to thicken the endometrium lining? Or that would work better than that?

It should be performed in a parallel model. If you have disrupted period, you should check your hormones and your physician should normalize your period, it’s just the first line. On the other hand, if you already had problems and your physician have removed the polyp, sometimes after removing the polyps if it was a hard intervention, it wasn’t so delicate, or your resources do not allow to make a great recovery. Naturally, sometimes we recommend PRP therapy as a tool of regenerative medicine to help your lining to recover and to start growing. First of all, you should find the reason why the lining isn’t growing. We call it resistant thin endometrium, we should find the reason and there are usually 2 reasons, dysregulated menstrual cycle and the presence of inflammation and you should work in both directions. 6.5 millimetres is very close to our aim, it’s always better to have more than 7 millimetres, but it’s much better, trust me, I have patients with the endometrium not more than 4 millimetres, and we have treated her till the normal size. Don’t be desperate, it’s really not a bad thing, you have to just take everything into the account, listen to a physician, and I’m sure that your physician will find the key to your endometrium and prepare it properly.

Does EmbryoGlue help implantation?

EmbryoGlue was suggested several years ago, and we tried it as we always try everything to enhance the results but unfortunately this supplement disappointed most clinics and most physicians. EmbryoGlue means that we add something which will help the embryo to implant. At this time, we can consider granulocyte colony-stimulating growth factor in the form of injections, subcutaneously in the abdomen, and it for sure will help because it’s the systematic activity which fixes the problem of deficits of GCSF in our organism and this growth factor plays a role of this natural glue for implantation, so that is the reason we do not implement EmbryoGlue anymore because it doesn’t work to tell you the truth. We have implemented a kind of glue, embryo glue but we administered it not during the practice of embryo cultivation but just from the day of embryo transfer.

Can you do a hysteroscopy and BeReady test at the same time?

Yes, for sure but we should follow the instructions of preparation to BeReady test, so we will make hysteroscopy from day 19 to 22 during your menstrual cycle and 5 days before hysteroscopy, you should start to take progesterone usually, we administer it in the form of vaginal gel because it’s so-called micronized, so it’s very similar to the natural ones. It’s considered more similar to our organism, but for sure, we can do it just at the same time.

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Fostering Fertility in the Workplace: Why does it matter?

What are the pros and cons of endometrial receptivity tests (ERA, Er-map)?

Choosing the right clinic for your treatment: why the ‘best’ may not be the ‘right’ one for you.

The exceptional role of hysteroscopy in the diagnosis of infertility: See and Treat

Authors

Diana Obidniak, MD

Dr Diana Obidniak, MD is the Head of ART of Birth Clinic in St. Petersburg, Russia. Dr Obidniak is a Fertility Specialist, Affiliated Professor at St. Petersburg State University. She is also a member of the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology (ESHRE). She is also a National Representative of Russia at the ESHRE Committee.

Event Moderator

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.

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