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.
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.