Comparing different embryo grading systems

Ana Sousa Ramos
Laboratory Manager & Clinical Embryologist (ESHRE)

Donor Eggs, Embryo Transfer, IVF laboratory

From this video you will find out:
  • Why do we need to select the embryos?
  • At what stage it is best to select the embryos for transfer?
  • How is embryo grading performed?
  • Why are there different IVF grading systems for Day-3 & Day-5 embryos?
  • What does morphokinetics add to embryo selection?

What methods of embryo scoring are used?

In this session, Ana Sousa Ramos, Laboratory Manager, Clinical Embryologist (ESHRE) at AVA Clinic, Lisbon, Portugal, who has discussed the differences in embryo grading systems.

- Questions and Answers

Would you select an embryo with the best ICM (inner cell mass) and then the best TE (trophectoderm)?

Recent studies show that it is better to select the trophectoderm. If you have 2 blastocysts and 1 is with a good ICM, and the other doesn’t have a good ICM but has a very good trophectoderm, you choose the one with a very good trophectoderm.

It is up to the embryologist to choose the embryo in this situation, depending on how it is done in this specific lab. It is very important because the ICM will develop the embryo afterwards, but you have to have something that is equilibrated between the ICM and the trophectoderm. Sometimes it’s difficult to decide, you have to see the blastocysts to decide, but the latest studies show the best implantation rate is related to the best trophectoderm.

I was diagnosed with high NK cells. Do you think I would have better chances to transfer 2 day-5 embryos together?

If you’re less than 38-years-old, even with your diagnosis, I would go for a single embryo transfer since you have blastocysts instead of transferring 2. So, I’m not sure about your age, but it is important to know that.

Do you freeze morula embryos? Is there a risk of denaturation during cryopreservation?

As I’ve mentioned, freezing at the morula stage is not so common. The embryologists usually don’t like this stage. In my experience, sometimes, I do prefer freezing at the morula stage and thawing after for a frozen embryo transfer cycle. I freeze morulas, and then I thaw it 1 day before the transfer, and morulas survive nearly 100%. Thanks to the vitrification method good morulas have a very good survival rate. You need to have a well-established vitrification procedure, the blastocyst cell cavity interferences with water, the blastocyst has cryoprotectants that interfere with the survival rate. That’s why some centres do like to collapse the blastocyst before freezing. I don’t collapse the blastocysts, and I have good results. In our centre, I do most of the freezing on the blastocyst stage, but in my experience, the rates with morulas are very good.

If you just have one fertilized egg, do you use blastocyst culture?

Not everybody agrees on that. I think that it depends on the overall treatment. You have to see the couple you are going to treat, you have to know how many attempts they had, how old they are. Most important is if they are prepared for not having a transfer. For instance, in my clinic, I had older patients, in Portugal, we can do treatments up to 50 years old with egg donation, but sometimes they have their own last try with their own eggs, and the next step will be a donation. You have to talk with the patients, you have to see if they are prepared for this. For example, in Scandinavian countries, some people prefer a more natural cycle, and sometimes they believe that the conditions of the women are better than the incubators in the lab, and sometimes they want to give it a try, and they prefer not to transfer at the blastocyst stage. Therefore, we should always talk with the patients to recognize their expectations.

 I’m 44, I have low AMH, NK cells are okay, I had 4 previous failures with my own eggs. In my last round, I got 2 good blastocysts. What do you recommend?

At 44, I would recommend doing the genetic testing of the embryos. If you get 2 blastocysts, and if they are of good quality, you can do preimplantation genetic testing to see if they are okay, because, after 40, you have an increase of aneuploid embryos and trisomies. In most clinics, when you have so many failures with your eggs, usually they start to recommend going for the egg donation process. If you still want to try with your own eggs, I understand that, but you should try doing the preimplantation genetic testing. I’m not sure if the quality of blastocyst quality will allow you to do the preimplantation genetic testing, but it’s something that you have to consider.
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Ana Sousa Ramos

Ana Sousa Ramos

Ana Sousa Ramos is a Laboratory Manager, Clinical Embryologist (ESHRE) at AVA Clinic in Lisbon, Portugal. Ana is also an experienced Laboratory Director with a demonstrated history of working in the hospital & health care industry. Skilled in Clinical Research, Medical Education, Life Sciences, Laboratory Skills, and Medicine. Strong research professional with a Post-graduation course focused in Bioethics/Medical Ethics from Universidade de Lisboa-Faculdade de Medicina.
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Caroline Kulczycka

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.