Hana Visnova, MUDr., PhD
Medical Director at IVF CUBE, IVF CUBE
Category:
Advanced Maternal Age, IVF Abroad, Success Rates
IVF success rates may be the trigger to the decision about choosing the IVF clinic. That’s why it’s highly important to realise how are they measured. During this #IVFWEBINARS and Q&A session, dr Hana Visnova – Medical Director at IVF Cube, explains how to understand the options of success during the IVF treatment. She describes what the typical statistical methods are and how to compare different results that patients may find on the websites of IVF clinics or in the scientific literature.
Dr Hana Visnova admits that success rates are the information fertility patients are usually most concerned about. All of them want to know what their chances of getting pregnant are. However, we need to specify what the pregnancy rate means. First of all, it may be understood per treatment commenced – this includes all the female patients who start any kind of hormonal stimulation. Secondly, the pregnancy rate can be related to egg retrieval. Unfortunately, not every patient starting IVF treatment will reach the day of egg retrieval. It depends on her age, hormonal situation and many other factors. There is a huge gap between the number of treatments started and the number of females who achieve their goal of egg retrieval. Thirdly, we can talk about pregnancy rates in terms of the number of women who underwent the embryo transfer. So when talking to a medical specialist, always ask them about their way of calculating pregnancy rates and your own individual chances. If you decide to invest your money, time and – most importantly – emotions, it is crucial to have this knowledge prior to the beginning of any hormonal stimulation.
According to dr Visnova, when talking about pregnancy rates, we also need to understand how many embryos are used for embryo transfers. There is a number of countries and clinics that perform just elective single embryo transfers (ET). It means the very best embryos are picked-up from a larger group of embryos. This can help to reach higher pregnancy rates compared to single embryo transfers where there are no surplus embryos for better selection. In the countries where two, three or more embryos are used for transfer, the pregnancy rates are higher, too.
However, dr Hana Visnova pays attention to the risks of multiple embryo transfers. Remember that you should always consider your safety when you start IVF treatment. And the best pregnancy for every woman is a singleton pregnancy. Only such a pregnancy gives the best chances of an uncomplicated course of pregnancy, uncomplicated delivery and the child’s best health conditions. If you decide on IVF treatment in a clinic accepting 3 or more embryos for transfer, then you must accept a higher risk of potential complications. So according to dr Visnova, one should always look for information on how many embryos are transferred to the womb in one treatment cycle.
Additionally, one of the most important prognostic factors is the age of a female. Scientific literature reports pregnancy rates in different age cohorts separately. If you want to know your individual chances of success, always check what age group you belong to. It is obvious that pregnancy rates for 25-year old girls will differ a great deal from the pregnancy rates in a group of women who are 35-45 years old. Unfortunately, there is a decline in success rates according to the increasing woman’s age.
Understanding pregnancy rates is one thing. Apart from that, we need to know if embryos were genetically tested prior to the transfer. Dr Visnova reminds us that the embryos screened with the use of preimplantation genetic testing methods (PGT-A) always give higher pregnancy chances compared to the not tested ones. In this way, genetically abnormal embryos are eliminated from the embryo transfer. The embryos are more precisely selected and the success rates go up to 65% (per single embryo transfer). Thus, patients do not lose time on embryos which would never get implanted anyway and shorten their time to achieve pregnancy.
As dr Hana Visnova explains, there are a few more ways in which success rates are calculated. While pregnancy rate means how many women get pregnant, the implantation rate refers to the number of embryos that implant in the uterus. If we calculate fresh embryo transfers and also consider frozen embryo transfers in the near future, then we speak about the cumulative pregnancy rate. Take home baby rate or live birth rate is the number of children born after successful treatment. The live birth rate also includes twin rates. No matter if there is a singleton or double embryo transfer, they should be calculated as one birth and not two babies born. However, if there are e.g. three embryos transferred and three times a singleton pregnancy, we can speak about cumulative live birth rate.
Another way in which we can understand success rates is a cumulative oocyte-to-baby rate. In general, it means how many eggs a patient needs to get retrieved (or obtained from the donor) to result in a baby, understood as a successful pregnancy and a delivery. If you have fresh eggs available for the embryo transfer and you belong to the group of patients with a good prognosis or this is egg donation treatment, then you probably need 7.6 eggs to have a baby. But if you use frozen eggs, in egg donation programmes, or do social freezing then the number of eggs needed to have a good chance of pregnancy is significantly higher – 14 eggs. Of course, the latter does not refer to females above 45 years of age – there, a woman needs about 30 eggs (in case of social freezing) to have a 90% chance of pregnancy.
According to dr Hana Visnova, pregnancy rates calculations should not include biochemical pregnancies. One can only include pregnancies which are confirmed with the ultrasound. Viable clinical pregnancy means that it is possible to see a gestational sac with a healthy embryo and a heartbeat. The next step is an ongoing pregnancy – when the first trimester was completed and the pregnancy has an excellent prognosis to continue further.
Once you want to understand pregnancy rates, you should also realise that, unfortunately, some pregnancies end with a miscarriage. Most medical complications that result in pregnancy terminations are related to maternal health conditions, her medical history or advanced age.
Finally, dr Hana Visnova highlights that good cooperation between an IVF clinic and its patients is needed to provide reliable success rates. Medics need the patients to report deliveries and abortions as well as information on the health condition of children born. Only in this way IVF clinics can be exact and have complete statistical data available for next intended parents. This is crucial in order not to underestimate or overstate people’s chances of getting pregnant through IVF treatment.
The success rate is related to the age group of the patients and to the number of embryos transferred. So if we have a patient with good prognosis in her first cycle and her age is under 35, then the pregnancy rate is around 50%. The same for the second cycle, when we’re speaking about the single embryo transfer on day 5 – the single blastocyst transfer.
The average number of embryos transferred at our clinic is 1.4. The chance of a multiple birth for a single embryo transfer is to 1.3, as the monogenic twins develop in 1 percent of all single embryo transfers. For a double embryo transfer, there is a chance of 20% to get a twin pregnancy – from 5 pregnant women we expect a twin pregnancy in one of them.
With AMH of 3.85 pmol/l and 30 years of age, I would expect 4 eggs to be retrieved.
Of course, you are only 30 years old so you can have an excellent quality of eggs. So I’ll say, start the treatment as soon as you can. You have a very good chance to achieve a pregnancy, despite a low number of eggs and a low AMH levels, because you would probably get good quality eggs.
In our country, only a single embryo transfer is recommended for gestational surrogate mothers. But maybe you come from a country where it is possible to implant two embryos for a surrogate mother. So you should ask those countries where such practice is allowed.
Yes, we do have scientific data comparing success rates when a male partner has very low sperm count and his female partner is of different age group. We can say that the younger the female partner, the better the fertilisation rate. We can simplify it and say that a young egg can correct some abnormalities resulting from poor sperm quality. But the egg of a female in advanced age does not have such a capacity to improve DNA damage coming from the sperm.
I believe both methods are experimental, they are not a part of routine practice. There have been just a few deliveries reported. I do not have any personal experience and we don’t offer these methods in our clinic.
Unfortunately, most women at the age of 45 have very low AMH level and we don’t recommend any IVF treatment using our eggs anymore. But if your case is different, if your AMH level is really very high, and you can get a good number of embryos retrieved during the stimulation, then you should also consider genetic testing of embryos to eliminate aneuploidies – abnormal chromosome count. And if after the genetic testing of embryos you have at least one embryo with a good chromosomal count, then you can have a very good chance to get pregnant. But I need to add that in most women at the age of 45, despite good AMH level, we don’t identify any single genetically normal embryo. But you might be an exception, I am not familiar with your case.
In general, autism or Asperger’s syndrome or some psychiatric disorders are probably linked to the advanced paternal age. So older males are statistically more likely to get children with autism or similar syndromes. But we don’t know the reason yet. It is probably not related to the egg donation so there might be no difference if you do egg donation or own egg treatment. It is a simple age-related risk, related to the advanced age of the father.
The definition of an old father refers to males who are over 60 or even 70 years of age. A 42-year old is considered a younger father. I would not be worried about a higher risk of autism as compared to the general population.
It’s a difficult question. In our clinic, we always recommend genetic testing of embryos for women at the age of 40. And we hope that, in one or maybe two of those cycles, we will be able to find genetically healthy embryos suitable for the embryo transfer. If we have an embryo with a normal count of chromosomes, then we can have 50-60% success rate. But sometimes we don’t find any healthy embryos and we aren’t able to proceed with the embryo transfer. But if you think of 3 cycles and if we get, let’s say, 10 eggs for each cycle, then I hope that there will be at least one good embryo available among them.
I believe that in case of a double donation there is no medical reason to perform PGT-A. Generally, both egg donor and male donor must be young. But of course, it depends on the local practice and legislation of each country. It might be different.
I’m afraid this question should be addressed to a pediatrician or a psychiatrist. This is not a part of IVF treatment. You should seek for statistical data regarding age groups of fathers. I am not the right person to answer this question.
Yes, we do offer embryo adoption in our clinic. I don’t know what you mean by ‘many embryos’. We have a substantial number of embryos to choose from and to match to you according to your phenotype before embryo adoption.
I don’t see any reason to perform HCG before egg donation. I don’t understand the reason to do the investigation and I do agree with you that the procedure might be uncomfortable and sometimes a little bit painful – not very painful, in fact. I don’t think it’s necessary to be performed.
If the AMH level of the 20-year old donor is average, the dose of stimulation drugs is well decided and the stimulation is performed by a well-qualified specialist, then I’ll expect 15 to 20 eggs to be retrieved. If the sperm of the intended father at the age of 42 is normal, then from those eggs, there might be 15-17 eggs fertilised. It means that we can expect 5-6 embryos to develop further into good quality blastocysts.
As I explained earlier, in our clinic we recommend genetic testing of embryos. So it depends on the results of the genetic testing. It makes sense to store own embryos with normal genetic finding. But sometimes at the age of 42, we don’t have any surplus embryos available for longer storage. On average, we have good luck if we have at least one single embryo with normal genetic findings. And then we don’t have any surplus embryos left.
In egg donation, the legal limit for an egg donor is under 35 years of age. If you mean the recipient, the intended mother, then the legal limit is 49 years of age.
Yes, we are. But as I explained during my presentation, we are facing a lot of difficulties because of the lack of live birth rates reporting. We are facing some delays because it takes our patients a long time to respond to our questions regarding delivery details. There is usually a one-year delay. So I can present now little data on live birth related to treatments performed during 2017. Pregnancy takes 9 months anyway and usually, no one has time to respond one week after delivery. So there is usually one year needed, since the treatment, to have all the details available.
The quality of oocytes is strictly related to the age of the female. So actually the examination of the quality is the birth rate. AMH testing or ultrasound testing can tell you the quantity, how many eggs could be retrieved. But when it comes to quality, there is only criteria and this is the age.
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