When it comes to infertility treatment, it is generally believed that a personal approach and treatment adjustments are the key to success. How then can guarantees be possible? Is it possible to predict treatment success or a failure from the beginning? What are the risk factors and how to avoid them? To solve these riddles, we did organised another #IVFWEBINARS with Dr Tomas Frgala – UNICA Clinic – in which he tried to explain the process of IVF with Donor Eggs and Guarantees.
Dr Tomas Frgala started with quite a pessimistic but still realistic remark: unfortunately, not all IVF treatments end with a positive outcome. There are many factors that can negatively influence the results of the procedure. Even though doctors review every cycle to identify aspects which could be improved there are inevitably cases when patients experience repeated implantation failures or repeated miscarriages. It is at this point where alternative solutions need to be considered.
When looking for reasons for repeated implantation failures or miscarriages, doctors always start with the basics. Firstly, they analyse the quality of sperm and egg cells as there is strong evidence that it is the quality of the embryo that influences the success (or failure) of IVF cycle. Supposedly, an embryo carries about 80% of the responsibility. The other 20% includes factors such as the condition of the uterus, endometrial receptivity, haematology, immunology, etc.
In the case of previous attempts without any success or when indications are quite obvious, egg donation is considered. Treatment with donated oocytes is recommended when a woman does not produce her own eggs (either if she does not have her own eggs or suffers from POI – premature ovarian insufficiency) or if the eggs are of poor quality. There are also cases with severe endometriosis or clear genetic recommendation which may lead to the conception of unhealthy embryos. Last but not least, it is the woman’s age – the factor that is the most important when it comes to the good quality eggs from one’s own ovarian reserve.
A woman’s advanced age is generally connected with all the above-mentioned factors.. Dr Tomas Frgala recalls the statistics showing that 18 years ago in the Czech Republic the average age of women getting pregnant was around 30. Now it’s over 35 years old. Although women choose to get pregnant later, the evolution doesn’t hold a step here. Egg quality is still the best at 19-30 years of age after which it starts to drop and around the age of 40, it becomes difficult for a women to achieve a pregnancy with her own eggs.
When a woman chooses a cycle with donated eggs, it is important to consider the basic rules in the country where she plans to undergo the treatment. These rules might differ from country to country. We should pay attention to who the donors are, how they are selected and matched with a recipient as well as if egg donation is anonymous or not. It is also good to understand the reasons why donors donate. Dr Frgala admits he was quite intrigued and pleasantly surprised by the study conducted by ESHRE (European Society of Human Reproduction and Embryology), issued in 2017, showing that 50% of donors gave pure altruism as the primary and only reason for their decision about donating eggs.
The process of egg donation for the recipient is quite simple. It is the donor who goes through a series of check-ups including ultrasounds and applies hormonal injections on a daily basis. She then undergoes egg retrieval under complete anaesthesia. The retrieved eggs are fertilised with male patient’s sperm and the embryo is cultivated. For the female patient, the whole procedure usually includes one visit to a clinic for the embryo transfer. Patients are often interested in what medications they will have to take in order to prepare the endometrium (the lining of the uterus) for receiving the embryo. Dr Tomas Frgala says these are mainly estrogens (in the first initial two weeks to build up the endometrium) and then progesterone to make the endometrium ready for the embryo. The lining evolvement in the uterine cavity is checked by ultrasounds usually around day 10, 11 or 12 of the estrogen application. Doctors qualify endometrium as optimal when it has acquired a trilaminar or triple-line structure. The ideal endometrial thickness is 7-10 mm.
However Dr Frgala states, the success of the procedure lies with the embryo itself. There are several options when to transfer the embryo – either on day 3 or day 5 of the cultivation. According to embryologists, the first three days are the most decisive and influential. From day 4, the quality of the genome from both the egg and the sperm starts to show. It is usually around day 5 that many of the embryos show their potential and either slow down or stop completely. Dr Tomas Frgala highlights that it is not a mistake to transfer the embryo before 3 days but, at the same time, he admits that a lot more can be learned about the embryos by transferring them on day 5. An embryo in vitro culture is a selection process. One has to remember that each embryo’s progress is evaluated thoroughly and then the decision is taken on which day it is most likely to implant successfully.
Another interesting issue is the number of eggs to retrieve. As Dr Tomas Frgala puts it, the process of fertility treatment is complex and at every step, some of the strength in numbers may be lost. Firstly, not all the eggs collected will be mature and suitable for fertilization. Secondly, not all the mature eggs will be successfully fertilised in spite of using ICSI method. Lastly, some embryos will fail to develop correctly during the initial 5-day in vitro cultivation. That’s why it is a priority to start with the sufficient number of eggs that would lead to a promising number of healthy embryos on day 5 – both for the transfer and for cryopreservation.
Dr Frgala admits that success rates with egg donation are generally quite high. That’s why many IVF clinics now offer guarantees for egg donation treatment. The guarantees have much to do with both previously mentioned statistics and biological processes and the advancements in technology, such as e.g. vitrification. The latter is a modern cryopreservation method that ensures blastocyst survival (with the same unchanged quality) up to 99%.
There are different types of guarantees, such as a guarantee of oocytes or embryos as well as pregnancy or live birth guarantee. As it is the embryo that carries the most responsibility for the success of IVF treatment, Dr Tomas Frgala advises looking for offers with embryo guarantees and not oocytes guarantees. Even more crucial is to look for guarantees with embryos at the blastocyst stage. However, according to Dr Frgala, it is best to seek guarantees with a clinical pregnancy. The reason is the risk of early miscarriages between weeks 5 and 8 of the pregnancy. Fortunately, in egg donation miscarriage rates are much lower after heartbeat confirmation than in IVF with own eggs.
The novelty are IVF programmes with live birth guarantees. They represent a sort of risk sharing between a clinic and a patient. Patients are refunded part of the money spent if programmes are unsuccessful. Dr Frgala admits that although live birth programmes are quite expensive, they make a lot of sense. They give patients a feeling of security – both in a psychological aspect and a financial one. Generally, guarantees have much to do with giving patients peace of mind, motivation and new hope.- Questions and Answers