By fertility experts from Spain.
In this webinar, Dr. Zineb Meski, a Specialist in Assisted Reproduction at IVF-Spain Madrid has been discussing some alternative family options for women like ROPA method for lesbian couples as well as options for single women.
We use the new generation tests for the PGS, so that means we do a sequencing of the DNA and, it depends, of course, if we are going to do a PGS or a PGT for the aneuploidy, so aneuploidy, which basically looks for the chromosomal abnormalities like Down Syndrome or any kind of trisomy, that will be the PGS for aneuploidies, so that’s the screening. We are going to look for a specific genetic disease like cystic fibrosis or any other diseases that are known to be carried in the patient. We will use the new generation sequencing method (NGS).
You mean without doing the biopsy on the embryo. There is no other method unfortunately, we need to take out some cells from the embryo to analyze those cells and to have some DNA of the embryo, so for now, that’s the only method. There are some other methods, but it’s not a PGS, that means that we are not going to know before the embryo transfer, that’s the new no invasive methods that are used during the pregnancy. We can do a blood test, which means that there is DNA of the embryo in the blood of the mother, of the bearing mother, but she will already be pregnant. If there is a bad result or some abnormality during the pregnancy, there is a decision that needs to be made. Whether to keep going with the pregnancy or terminate the pregnancy.
That’s why we prefer to do the PGS because it will be a diagnosis before we implant the embryo, and the only way to know that, is to do the biopsy, but it’s safe. That’s why we need the embryo to get to the blastocyst stage otherwise, the embryo on day-3 will have very few cells, and if we take out one or two cells, first we take the risk that we won’t have enough genetic DNA material to analyze and the results will not be so reliable. Second, we can damage the embryo because it has only a few cells, 8 cells, and if we take 1 or 2, it’s a lot comparing to a blastocyst stage when usually they have around 200 cells, so it’s a safe method.
When we do the PGS, the transfer can be the month after the egg collection because first, we need to wait for the results, and as I said, it can take around 2 to 3 weeks to get them, so it’s 3 weeks after the biopsy, and the egg collection is done 5 days before that, so if we do the math, it’s almost a month. We can start doing the preparation for the embryo transfer before that, it depends on the period, of course, all the treatments that I’ve talked about they have to start with a period ideally, but we can also trigger the period if it needs to be done if we need to schedule the treatment for a specific date or just start with a birth control pill with your period so we can just pause your natural cycle and start, whenever we want so we don’t need to depend on your period so that date can be planned ahead of time. It’s a little bit better to do it according to your body, but we will control your body with all the preparation, we will give you the medication, so the endometrium gets thicker, and your body gets prepared, so it’s planned actually.
I didn’t really talk about it, but it’s also an option. When I said double donation, it also means embryo adoption that could also be a good option for these women. There is not a very long waiting list, it’s really up to the embryos that are available now. The patients that have already done treatments with us, and most of them got already pregnant, and they don’t want to use any more of their frozen embryos that are left, they get this option to donate them to other patients, so according to the Spanish law, only the patients that are under 35, female patients that are under 35 when they did their cycles with us can donate these embryos. They donate them, we just need the authorization. These patients need to sign all these consents, so we can use those embryos for other women.
Sometimes, we have a number of embryos that are already available but, of course, we need to match the phenotype. The law does not strictly say that we have to match the exact same phenotype, but we always have to respect the ethnicity at least and try to respect blood types. Especially, the most uncommon ones that can be a problem like a negative rhesus blood types, but it’s like secondary, it’s not like when we research a specific egg donor.
Then, we have to respect all the phenotypes, but here it’s a little bit different, we just try to get the closest patients to your ethnicity, and if there is an available embryo, we just assign that embryo to you, and you can start right away, so I think that the longest waiting list that we had was about 3 months, so usually, it doesn’t exceed 3 months.
We do have some embryos that are generated from black or mixed couples. As you know IVF -Spain is a group of clinics that are very open to international patients, so we have all kinds of ethnicities. We have several types of embryos that are listed in our embryo bank and sometimes there could be a little bit of more waiting, but that’s only because maybe there are several patients that are also looking for it. Usually, it’s not an issue, we do have a very wide range of ethnicities.
This is a very interesting question also because sometimes patients do get a little bit confused about the timings and about all these side effects of the stimulation. Actually, we just need you to get your period again, we need to do a checkup once you have your period after the egg retrieval, usually, it’s a week after the egg retrieval, you’ll get your period, and with that period, we’ll do an ultrasound to make sure that everything is back to normal. If you have no cysts, no side effects of the stimulation, we can start a second stimulation right away, so yes, a week after the egg retrieval when you get your period, we can start the next stimulation, again.
Here in Spain, you cannot use your brother’s sperm, as I said, it has to be strictly anonymous, so I mean the same-sex couple women can use the eggs, it’s not really considered as an egg donation because it’s a married couple or domestic partnership couple, but for sperm, it has to be an anonymous donor, so, unfortunately, the law, for now, hasn’t changed, and for the male couples, it’s not possible yet, and even for the sperm donors, they have to be strictly anonymous.
It’s a tricky one, well actually, it’s up to how the couple breaks up really because the ROPA program can only be offered for a married couple or domestic partnerships, so they both need to sign the consents, so legally all the embryos belong to both patients. If a couple breaks up, after all, it’s like in a heterosexual couple. If the couple breaks up, they need to see who gets the custody of the embryos, so it could be an arrangement between the couple, or it could be something that could get a little bit complicated, and sometimes, they’re not allowed to use those embryos, neither of them is allowed to use the embryo, so it’s not really up to our clinic, it’s up to the law and the lawyer’s decision, but you have to know that if you do the treatment, both of women will sign the consents as if they were both the parents of the future child.
Usually, age affects the quality of the eggs, the quantity and the quality of the eggs, so it doesn’t really affect the uterus. I mean it affects it but not as much as the quality of the eggs, so if the woman is healthy, if all the blood tests, all the testings are normal, the success rates are the same for double donation for a woman over 40 or a woman under 40 and these success rates can go up to 75% because we are going to make sure that there is a good egg quality from the egg donor and also a good sperm quality from the sperm donor and it’s only up to the uterus to be prepared and to have the best conditions for the embryos that will be generated from this double donation treatment to allow the embryo to implant. We are going to make sure we do all the tests before transferring the embryos, and the success rates usually are very high.
Actually, we always recommend doing an ultrasound before starting the injections just to make sure there are no cysts. Usually, when you’re on the pill, there are very low chances to have cysts, but sometimes it also happens, so we prefer to do that just to make sure there is absolutely nothing going on there before starting the stimulation because if you have a cyst that could interfere with all the stimulation, all the hormonal treatment and when you do an IVF we don’t want to start on the wrong foot as we say, we just want you to start with the best conditions to get the best outcome from your stimulation. Even if you didn’t have any cysts in the last ultrasound in summer, that was two months ago, and it can change from a cycle to another. I would recommend doing an ultrasound before starting just to make sure everything is fine.
PGS and the NGS method is quite reliable, actually, it’s like a 99% of reliable results, so it won’t decrease the abnormalities, it will just give us the information, it will just tell us which embryo is healthy and which one has an abnormality. When we do an embryo transfer knowing that the embryo is healthy, doesn’t have any of those genetic abnormalities, the risk decreases a lot, the risk of miscarriage, and of course, it will decrease a lot. I can’t give you a number because we don’t really get the chance to do the study between women that do the PGS and the risks of miscarriage. It’s really difficult to compare because either you do the PGS or you don’t with the same embryos. It’s very tricky to do a study, but it does decrease the risk of miscarriage because most of the miscarriages especially, in women that are close to 40 years old – are caused by a genetic abnormality.
You can have also some issues with your coagulation, window of implantation, other issues with your uterus like polyps or fibroids, but the most common ones are the genetic abnormalities. As for a sick child, as I said, PGS will only look for some specific genetic abnormalities, and we cannot look for all those genetic diseases, it’s really impossible, so even if we do PGS, you can still have a sick child, but that would be due to another kind of genetic problems, not chromosomal structure or chromosomal number problems. It would be some genetic mutations that as I said, we cannot test all of them.
The donors of the embryos can’t be over 40. As I said, according to the law the woman has to be under 35 to be authorized to donate embryos. As for her partner, there are some tests that we will need to do, like karyotype to see the chromosomes, we need to make sure that this couple that is going to donate their embryos don’t have any known genetic disease that can be transmitted to the embryo. If there are over 40 and they cannot donate them to other couples. Here in Spain, they are not allowed to destroy them. There is another option, and that’s to donate them to the investigation, but it’s also tricky because if there are no projects of investigation, the embryos. Sometimes, it is a bit of a problem to donate them for investigation because you need to have a Project, the current project, so they can use those embryos otherwise, they’ll just be frozen and will be waiting for a project to come.
This is an interesting question because we haven’t talked much about the numbers, but there are some statistics there that are very interesting, so usually, a woman at 35 years old a woman will have a 60% chance to have healthy embryos. 40% of the embryos are going to be health, then as she gets closer to 40 that range will decrease, the range of healthy embryos, so when she gets to 40 years old usually, it’s around only 40% of the embryos or even between 30-40% of the embryos are going to be health, that range gets like reversed, so 40 is going to be healthy and 60% is going to be abnormal. If we simplify it, only one out of four embryos is going to be healthy more or less. Of course, every woman is different, every person has a different body, different metabolism, so the best way to know is to do that PGS, that’s why we recommend doing it in every woman that is 40 years old or beyond.