In this session, Maria Escribá, Clinical Embryologist, IVF Laboratory and Andrology at Equipo Juana Crespo, Valencia, Spain, has discussed all the steps of quality management in the IVF lab, what systems are used and its purpose.
Quality control is a process by which IVF laboratories review the quality of all factors involved in all processes. Quality control in IVF is huge. There are so many factors involved and so many tasks that need to be done to have a good quality control. I’m going to summarize it, but if you want more information here you have the big definition of this.
Control quality management always follows this cycle. This is the key to quality control: plan, do, check, act.
When we want to do an action, first we have to plan it in detail. Then, we do it, we’re going to validate it, and then we check it every day if it’s working and everything it’s okay. It’s done with time because what we want is to improve. We will act, and again we will plan, do, check, and act. This is like the eternal cycle of control quality.
Here, there is a summary of many responsibilities and duties that are written in the ESHRE guidelines.
ESHRE is the European Society of Human Reproduction and Embryology. If all of these requirements are fulfilled, the clinic can apply for a certification of quality.
After an audit, the clinic can get a third-party certification on the conformity of services and processes. If this accreditation is obtained, the certificate can ensure patients that necessary standards are met.
There are official bodies, like ISO, which is the international organization for standardization. This is the most common, but every country has its own body.
It’s not very simple. It’s an important answer, but it’s really hard to get. What we want with quality control is to achieve the best outcomes, to get better results, always.
There are four means to achieve this quality:
They are under continuous marketing, checking, and testing.
The most common professionals in the lab are the embryologists who are highly skilled professionals that perform all procedures that take place in the lab. We take care of your embryos; we are the first babysitters of your embryos.
There are more technical answers, but I want to tell you that, for us, embryologists, what is important is just to be aware at all times, at every moment, of how important the task that we have at hand is because we have our embryos in our hands. We work with human embryos, with your future babies, so this is so important. That can be simple or very complicated, but we have your embryos in our hands, so we have to be fully aware of these. We have to be focused at all times.
Here we have an example of processes that are performed in the lab, like sperm preparation, pick up, ICSI, embryo grading, vitrification, throwing, assisted hatching, transfer, all of them, biopsy, more simple, more complicated, but all of them. All these processes, even cleaning a hood, all processes are always performed following an SOP.
SOP is a standard operating procedure, which is a detailed document that describes how a task is to be performed. All embryologists in the lab perform every procedure in the same way. If not, we would have different outcomes, so this is important. We all do the same procedure in the same way with the same quality. With time, SOP should be reviewed regularly to improve them according to the cycle that’s related to the plan, do, check, act cycle.
At Equipo Juana Crespo, they have 4 labs, but all of them are more or less the same. The aim is to recreate the same natural conditions where the embryos live.
We want to create the best environment for them because an optimal embryo culture is equal to embryo quality. If we have a good culture, we will have good quality.
The IVF lab is a clean room which has an independent and a filtered climate machine. With this, we’ll get the control of temperature, which in our case it’s 21.5 degrees all year long. Here in Valencia, in summer, it’s very hot, not very cold in winter, but it’s cold. However, we have the same temperature all year long. This is very important.
We control the humidity and it’s a room with upper pressure, this means that the lab has more pressure than other rooms close to them, so all particles, dust, everything tends to go outside the lab. Thus, this makes this room very clean.
We have 15 cool air renovations per hour. This makes a very clean and safe room. Now with COVID-19, labs are really good and Covid-safe place because the air renovates a lot of times per hour.
In the lab, we need to avoid the VOCs. The VOCs are the Volatile Organic Compounds, these are a group of chemicals found in many products, and they’re released as gas, and we breathe them; they’re in the air. Nothing happens to us if we breathe them, but the embryos are very vulnerable, so we have to protect them from these organic compounds. Therefore, we have a lot of filters, very special filters, and the lab has to be built with special materials. We have to avoid the use of glue, silicones, and plastic. We use special furniture for the lab to avoid these VOCs.
Between the lab and the admin room, we have the lab hatch, which is an airlock with two doors, and only one can be open at the time. So, we have limited access to people, only embryologists can be inside the lab because your embryos are inside. This is very important, only we can be inside, and we have these particles with us, so the fewer people inside the lab, the better.
We have a system of traffic light doors; one is green, and one is red.
We have special calls to go inside.
We use specific cleaning products. This is very important.
We wear special clothes.
We prefer to use glass.
When naming equipment, I want to talk about technical equipment, such as microscopes, hoods, consumables, plasticware, glass or materials we use, all kinds of media, embryo media, oil vitrification media, and all media.
The consumables and equipment should be of the highest quality. This is very important because the better the quality of the consumables, the better the results. We will notice if you’re using good plastic dishes or not.
The technical equipment must be tested regularly and maintained every year, for example, microscopes, and incubators are very important to check when appropriate.
In the slide shown, some petri dishes have some wells where we put the droplets of media and we cover them with oil to avoid evaporation of the media. They are inside the media droplets covered with oil.
This is important because embryo culture is not only the media; we need to give stability to have a good embryo culture. This is made by controlling all the factors that affect embryo culture:
Temperature is really important because, as we said, we want to recreate the natural conditions. Inside the woman it’s 37 degrees, so embryos should be at 37 degrees always, at all times, everywhere not only in the incubators, but everywhere, in the hoods, microscopes, even if we leave them for 30 seconds that surface needs to be heated. Therefore, all these surfaces are heated, but it’s not that simple just to set the display at 37 degrees and everything else for this level. It’s very hard to keep this temperature, to have the same temperature on the whole surface and to have the same temperature everywhere and always, at all times.
What we do every day is to check the temperature. We have this temperature emitter with the fluke, incubators with buttons which are very useful because they are wireless. We can put them inside an incubator or in a surface and we can map it because we can leave them for 24 hours, for example, and they will keep record of the temperature every 10 minutes, and then we will have a full report of the how the surface is mapped with the temperature.
As I said before, consumables are really important because it’s not the same if dishes are completely flat and they are touching the surface or if they’re not and they have a little edge, so this is very important to have, at least, all dishes to be the same or flat or not.
It can be seen in the slide how important is temperature because 36, for example, we will have a blastocyst rate of 41% and at 37 we will have 48%, so one degree makes a big difference.
With regards gases and oxygen, we know that inside the womb and tubes, the oxygen is around 5%. It’s not like the air we breathe, so incubators have to be at the low percentage of oxygen because this is very important for the blastocyst rate.
Every week we have to check the oxygen with gas meters, and we have oxygen probes inside the incubators to make sure that it’s not only the display saying that we’re working at 5%, but we can also improve it.
The CO2 pressure allows us to achieve the desired value of pH. We want to achieve the some conditions that are inside the woman. We do this through the CO2 which is the means to control the pH. We set the CO2 and then we control and check these CO2 levels with these meters. This is a continuous CO2 meter, like a gas meter, and then weekly we have to measure the actual pH that we have in our culture because it’s important to know the pH that we have in our culture.
The image in the right corner is a continuous pH reader, and the image to the left is an Epoch. Once a week or at least when we change the batch of media, we want to make sure how is our Ph and we can measure it.
We have been talking about so many variables, but how do we know them? We can’t always measure them, so we have a system that monitors all these variables. We have a log with all these variables, and we can get alarms with this.
We have so many probes, and so many sensors for temperature, not only for incubators and for the room, but we also have for the fridge, for the freezer, and for the tanks where the embryos are inside when they are frozen. This is very important. We even have a power cat, so we register all of them, and we will get an alarm; thus, there’s no need to be in the lab to know that something is happening. You can be at home, at 5 in the morning, and you can get an alarm that something is happening.
Every day, before we start to work, we need to know that everything is in the optimal range: temperature, gases, everything. Therefore, before the start, we have this startup, and before leaving, we do a small shutdown so that everything is okay inside the lab.
We have record, we keep evidence of it and if you forget to write something, to enter a value, it’s going to tell you about the incidents, that you haven’t put these values, you have to put it. If something is wrong, it’s going to be like red so you know that this is not in range, that I have to take an action to sort this out. So, this is very useful for the quality control.
We can be sure that we’re doing everything we have to do, and we think that we have that quality control. However, how am I going to be sure of this? How do I know how competent is my lab according to ESHRE?
For example, there’s the ESHRE, the European Society of Human Reproduction, gave a guideline, that was the Vienna consensus, a report of experts explaining the main indicators for the lab.
Therefore, you can compare your indicators with this one to know in which range of quality you are working. These indicators are called KPIs. For the KPI, you need to calculate them per lap, every year, and every month. Thus, which month was better? What’s happening per the embryologist? When you’re working you think that everything is fine but maybe you’re not doing something or you have changed something, so you can check yourself that if you’re working properly.
According to this consensus, for example, it’s like the fertilization rate, cleavage rate, blastocyst rate, and implantation rate. They give this competency value which is the minimum competency limit to achieve quality.
We always have to be working more than this percentage of competency because this is the minimum. Our aspirational goal has to be the benchmark value, which is excellence. We need to achieve this one because we want to work through excellence, and if you’re in a range between 10%, for example, how can you work towards getting this value, the benchmark you want, the excellent one? This can be done with the plan, do, check, act cycle. You review and update your SOP, trying to improve it, and you talk with other people. It’s like better processes, better everything better. You can get better disposables, everything, because we are always working towards the benchmark value, always.
I think this is very important for you and us. It’s something that it’s not going to improve the quality, it’s not going to give us better results, but it’s going to give us a lot of safety. I think that safety is also quality, always. It’s the sample identification and traceability of your samples.
Many of you ask, for example, ‘How do I know that my embryos are my embryos?’ From the beginning, from the pickup, day 0, with x sperm, they want it till day 5, day 6, day 7 to vitrification or to transfer; we need to keep this sample traceability. This is very important.
The first thing we do when we take a dish we have to read the name. We have to make sure that we have the protocol of the patient, and we have the patient read these. We read them and we’re sure that we’re working with your samples.
Anyways, at critical points, for example ICSI, when we are going to mix the gametes, sperm, and eggs, we call another embryologist to have a double witness. This human double witness is to make sure you have everything there, that you’re reading, and the other embryologist is reading.
Nowadays, with the new technologies, we have electronic witness systems. There are many models. They have electronic evidence that all the samples are from a patient.
We have a system of stickers and QR codes that we scan, and we read so we know everything is okay and we are following the traceability of your samples.
Here’s where I have a video, so let’s watch it.
Yes, we use video time-lapse for embryos, and when we are using donor eggs, it’s never an exact number because some donors have, or more extra donors, it’s like we can’t control that, but with egg donation, it’s much better to have good quality embryos than to have a lot of embryos, is what I think. I know that we need to have both of them, especially when you go for an egg donation. You want to have a lot of embryos, but this is not about number; it’s about quality. It’s about the quality of the embryos.
Usually, we have like a round average; we have like 10 eggs, sometimes we have 12, sometimes we have 8, but the important thing is how many blastocysts we are getting and the quality of these. Usually, we have good quality blastocysts because they are donated. We know our donors, and they are quite good.
I wouldn’t recommend PGS testing because the donors are usually very young girls, so they have good quality blastocysts and PGS is not mandatory at all. If sometimes you wonder if you have a really bad sperm, you can do it but I wouldn’t recommend in general PGS testing for donor eggs.
Well, not all of them for sure follow the same higher standard guidelines, but I want to believe that at least the minimum standards that the experts say we all follow and we all get. The minimum competency bar that I was talking about, but I know because I’ve seen that, not all of them work towards getting this excellency value. It’s like, how can I trust all of them when you go to a clinic?
I think it’s very important to do some research about this clinic, and how they work, or you can ask some questions to an embryologist if you’re doing the cycle. I’m sure that if you speak with them, you can ask all the questions you want and they will answer all of them for you. This way, they will explain the standards of quality they’re using in the lab. Some labs are better than others, but at least I want to believe that they’re good, at least, all of them.
In my case, I can tell you that we had that at the beginning when we started the clinic because our clinic is, like, 4 or 5 years old. Immediately, we were working towards getting this ISO accreditation. We have it, and then we have the UNE, which is a Spanish accreditation. Every year, we have to renew these audits, not every year like mega big audits, but I think every two years are the big ones. Every year, we have to renew, we have to keep records and prove all these results and the quality control that we perform in the lab.
I think it’s for the previous question, I think it’s very important to know if in the lab that you’re going to, they have these ISO accreditations, UNE in Spain. I don’t know, but I’m sure in other countries they will have more accreditation of quality and, if they have it, at least you know that they’re working on a minimum of quality.
I’ve never worked in a public hospital, so I can’t tell you for sure how they perform. I think some of them are better than other ones, but what I’m sure of is that people try. Furthermore, I don’t know if they have all the technology, the first quality technology, but the embryologists are good for sure, and they work and want to improve their results first.
What I’m not sure about is if it’s about the technology they use. Some of them, the big ones, will have good technology, but maybe the small ones won’t have this very good and new technology.
I can’t tell you for sure because I’ve never been in a public hospital, but it’s like a private clinic, it’s the same. Some are better than others, ones It’s less so, doing research about the clinics before starting a cycle. I think it’s a very good option for patients.
Well, for sure, I can tell you that this is not normal. In egg donation, having 3 not good cycles is not normal. You can have one bad cycle because even if you want to control the parameters and your donor is very good, the stimulation is good, everything is fine, these are our biological samples, you can’t control all of them, sometimes a cycle is not good. You can have a bad cycle.
In this case, 3 cycles in a row. I don’t know if suspicion, but it’s really bad luck at least to have only one blastocyst per cycle, even with donor sperm and with different donors. It’s quite strange.
I don’t know because if something in the lab went wrong, it could be, we are all human, but all 3 times… Maybe with more information, I will tell you something else, but it’s not normal, at least. Sometimes, it’s like once in a month, we have a bad donation cycle, but we know that it’s not according to our standards. What we do is like, okay, we have this cycle. The cycle was not good for us, for our standards, so we’re going to change the donor. We’re going to try another cycle. We’re going to arrange this because this is not normal, and we know that it’s not normal. This is not what we want to give according to our quality standards, so we will repeat the cycle.
So, something happens but 3 cycles it’s quite strange, at least with donor eggs and donor sperm. It’s a low number of blastocysts, very low. One blastocyst per cycle. With this information I can tell you nothing else, that is not normal at least.
This is a very good question and a controversial question. I think I prefer fresh eggs, but this does not mean that frozen eggs are bad. I think it’s like with frozen eggs, we will not get a high blastocyst rate, it will be a small one. We won’t have five, we will have like four. In terms of the number of blastocysts that we have, this makes a difference, but the embryos are good and completely fine to implant to give healthy babies; that’s what we want. So, it’s not a problem to work with frozen eggs; it’s just that we need to know that we will get fewer blastocysts than with fresh eggs, according to our numbers and my opinion, but then we can get pregnancies, of course, and everything will be okay.
We need to be aware that sometimes, when we thaw these eggs, they don’t survive because it’s like the eggs are different to embryos. The survival rate of embryos is really good, especially in the blastocyst, but the eggs, just because of their shape, are different. Sometimes it’s completely fine, but sometimes it’s not good and not all of them survive.
If we have this in mind, we can give 2 eggs more to couples. If you have frozen eggs, you will get the same number of blastocysts and the same results of pregnancy, so it’s not a big problem. If you ask me what I prefer, I will say this because I think we will get more blastocyst, but it’s not a problem at all if we work with frozen eggs.
If you allow me, I would like to add to Sylvia that this applies, for example, when we want to freeze eggs for social reasons, we need to be aware of this, it’s not like, ‘Okay, now I’m going to freeze my eggs and I can live my life and I will have children definitely because I have frozen eggs. It works and it’s a very good option because sometimes we see this. When we throw the eggs, after the years, some of them don’t survive to thaw, and they get quite sad because they didn’t know this.
I reckon this is a good thing, it’s a good technique, but we need to be aware of what happens, and what happens is that sometimes in some patients the extra bib after throwing is not perfect, so we need to be aware that maybe we’re freezing eggs for social reasons in future this can happen. If you’re going to freeze your eggs and you have a few numbers of eggs frozen, I would recommend another cycle because the number of eggs here is important for the future.
No, it’s not like that. If you can have, with fortune, two transfers, hair gel is not a problem. What I was saying is like us, as an embryologist, we spend so many hours inside the lab and we are very close to the embryos and all the products, so we avoid all these cosmetics, but if you as a patient, come or the doctor that is performing the transfer has hair gel is not a problem at all. It’s not that dangerous. It’s not a problem.
Inside the incubators, we have like a device, it’s called the Epoch device. The day before we prepare some dishes with the media, we leave them overnight, and then in the morning, before opening the incubator to check the embryos, we take these dishes with media, and we measure the pH with this device that is on purpose for this to read the pH. We have one incubator that is a continuous speed reader, but for all incubators we use this thing.
We have external quality control, as I said, for these official bodies, like ISO and UNE in Spain, and then we have in Spain is called ASEBIR. They give us external quality control. This is about the embryo quality. They show you some videos of embryos. You have to grade them in different stages of different days and different stages of the embryo, and this is like an external quality control to make sure that only we do them, between embryologists, in the lab and between our clinic to compare to other clinics. So, we all have an external quality control of how we create the embryos, how we prepare the sperm, and other things and for quality control, to have a record of all these things. We have the ISO and the UNE.
This is a good question. It’s more for the gynaecologist, but in my clinic, most of our cycles are frozen. They are not the fresh cycles because sometimes the endometrial during the cycle with hormones is not perfect, so freezing embryos is not a problem at all. We prefer to freeze the embryos, and then doctors prepare the endometrium perfectly, and when they are prepared, we will do a transfer, there’s no problem.
We prefer that, but this is the thing that embryologists aren’t deciding. I think it’s the doctors when we check the patients; they check, and they know if you’re okay to go for a first cycle or if you’re better to go for a frozen cycle. It’s just more of a gynaecologist question.
I think it’s around 87%. In my opinion, it was 67%, 90%. It’s a good survival rate, but it’s not as good as embryos because embryos are always close to 99%, so it’s still good, but for us, it’s like it’s not perfect. That’s what I wanted to say, that because it’s not about things we need to be aware of because I think we have to give all the information to patients when they need to know, and the survival rate of frozen eggs is not perfect; it’s like around 95 -90%.
We try. The problem is this is impossible because donors, some of them have their own children, and if it’s not the first time that they are donating, it’s like, you know, how was the previous cycle? This gives us a lot of information. If you know how the previous cycle was, you can control this cycle because you know the quality of those eggs, but there’s always a first time for everything, so sometimes it’s like we have more eggs if it’s the first donation and with a good stimulation they make a lot of control to donors, genetic, a lot of tests, everything with good stimulation, even if it’s the first time usually we get good results.
As I said before, sometimes this happens. It’s the first cycle, you don’t know, and the cycle is not good, so you tell the patient the cycle was not according what our quality standards, we will repeat the cycle because this is not what we were expecting for your cycle, so we will change and you explore the donor and maybe you can do something because something happened during the stimulation or if not, you will, according to what happened, the donation team will decide what to do with the donor. It’s better if it’s a proven donor, but that’s impossible at all times because we all have a first time for everything, and donors always have a first time, always.
This depends on the age when the eggs are frozen and their quality of the eggs. I mean, if the patient has a problem like endometriosis or another problem with the quality of eggs, just by looking at the eggs, sometimes we know because they are bad, maybe they can look good, but we don’t know really. We will know about the embryo quality, the eggs don’t give much information, so this is difficult.
I think the most important parameter here is the age. The age when you freeze. If you freeze your eggs when you’re 25, it is perfect. If you are 38 when you freeze them, it’s not that good because many of them are going to be aneuploid, so it’s not that good. So, age is the critical point here.
When you get older, you will have fewer eggs so that’s why I said if you’re 37 when you freeze your eggs and you have only five eggs, I would recommend another cycle at least, but if you’re young like 26 and everything is good, 8 eggs are fine, but if you’re like 37 and the eggs are not good, 7 is not enough most probably. There are always the thought of parameters and things. It’s not an easy question or an easy answer, so we need to check out the parameters, and the variables about patients to give an accurate answer.
It will depend on many things. Firstly, age. You said after 38. It’s not the same 38 as 40, but 38. It’s very important to know what kind of embryos we have, I mean, day of freezing, if they are day-3 embryos or they’re blastocysts. If they’re day-3 blastocysts, I will recommend after 38, I will recommend 2. If it’s a blastocyst, it will depend on the quality. If it’s a good embryo, we can have a chance with one. But it’s like the doctor has a lot to say because we will have to check, and we will need to know about the uterus. Sometimes, we have other patients who have a lot of problems in the uterus and the endometrium, so some parts of the womb are not okay. They need to transfer more embryos to have more chances for implantation.
Again, this depends on a lot of factors, but mainly the day of freezing, age, and quality of the uterus.
Some clinics make these packs, and 6 is a very common pack. With 6 eggs, you should have at least one transfer of blastocyst with one or two blastocysts. I guess if you’re lucky, you can have more, but per average with this pack of 6, at least you have one transfer of a good blastocyst, and they’re frozen because it’s simpler for the clinic than you can have, you stimulate the donor, and then you freeze the eggs. Then you can match these eggs with the recipient.
If you use fresh eggs, it’s a hassle, but I should think. It’s worth it, but it’s a hustle because you have to synchronize the donor with the recipient, you need to do it in this way, so it’s like the donor, when is the egg collection, the pickup of the donor, the husband needs to come as the husband has to give the sample. If we want to do the first transfer, the recipient should be synchronized with the donor on day 5 of the endometrium line. We will transfer the blastocyst so it’s easier to work with frozen donor eggs. As I said, it’s not a problem if you are aware of this. It’s not a problem, but mostly in packs of six because with six per average, you will get a good transfer for blastocyst. Maybe with only one, you won’t have spare embryos for a second child, but at least you will have a good transfer you will have.
Age is a limit when using your own eggs. You can try, always if you’re over 40, but then I will recommend using the PGS test. The chances are not that good, but I mean, you can try. It depends a lot on the quality. If you have any problems with the ovarian reserve, there are so many factors, but I mean, you can try. It’s not a problem if you’re over 40. I mean, it’s not a problem if you think it’s fine, you can try, and we can have good results, but the age is a limit when using your own eggs.
Some clinics are working on it. It has some advantages. It’s not having great results, but for some patients, it’s working. This is only for a special kind of patient who has eggs but they are not mature, so they can try. Perhaps this is not going to change the day cycle from night to day, but they can have a minimum improvement. They can have maybe 1 embryo for the cycle with this thing, and for them, having 1 embryo more is very important. Even if it is not a big change, it‘s important for them. The state is not well-defined; some clinics are working on it, and other ones are not, but they’re trying.
Nowadays, I think it‘s not a big thing and we‘re not getting big results, but maybe this is for the future, and this could be a very important thing. We always have to do research and we have to try these things for the future. In the future it will be okay, now it‘s not, but we are working on it to improve this and maybe in three years times it will be much better and special groups of patients they can be very happy with these techniques.
In our clinic, we perform the transfer in the evening, and we try to thaw in the morning because we like to see how the embryos react when we thaw them, they collapse, so we wait at least a minimum, I think, minimum we have to wait two hours because we want to see the reaction. If you wait more hours, you can see how they react and sometimes it‘s beautiful when you see that the embryo collapsed, but at the time of the transfer will fully expand, hatching, and it‘s a very good, big embryo. So, patients can see the embryos, they’re happy, and you have information of this because sometimes as you thaw them two hours after, the embryo is still collapsed, it‘s not presenting a good aspect, so you can speak with the patient, this has happened if you have spare embryos do you want to thaw another embryo and you can speak with them, you have time to react and it‘s good to always have information of the embryos of how they react after the thawing.
If you wait a minimum of 2 hours, I think it‘s better if you wait four hours to see how they re-expand, how they grow, you get more information about them, so you know more about the result because if it‘s an embryo is good and it was fully re-expanded, it was beautiful, and it‘s a negative, you can think of maybe the endometrium preparation was the problem, not the embryo.
If after four hours after the thawing, the embryo was not good and it‘s a negative. You can think that maybe this is an embryo problem, so you have more information if you wait some hours.
The cleavage is the same. You don’t need to wait like four hours because they are not going to collapse, but sometimes you can see them growing and then on the transfer, they are not a cleavage embryo anymore. You can see them more or less, so you know that the embryo, after the throwing, it is growing, it‘s dividing, it‘s like compacting now, so you have the same, you have information of the embryo and you’re happy because it‘s like you can see how the embryo has reacted to the thawing.
This is obvious that sperm with a TESA is not fresh or good sperm, but sometimes one thing is clear: what we have is what we have, so patients need to decide what they want to do.
If they want to give a chance with their own sperm, even if it‘s bad, they need to know that the cycle is not going to be as good as with donor sperm, but some patients want to give it a try, and this is okay. Why not? They want to try, and maybe they can get pregnant, and it‘s good. The results are not going to be the same with donor sperm or even with our normal sperm, but with the TESA techniques, we fish before the ICSI. Fish means that we‘re going like fishing, we‘re going to try to find sperm, not only to find the sperm, but they also have to move so we know that they’re they are alive, they’re moving and we spend a lot of time trying to find the best sperms according to morphology. According to morphology, if they’re good, they tend to be normal. If they are very aberrant, then the cycle will be much worse, but what we need to know is what we have.
Firstly, we need to know what we have, and sometimes, even we don’t get anything after the TESA, so considering having a donor sperm is good. It’s good to have like a plan B if we can’t get any sperm or if they prefer ‘I want to have a good cycle; I will go straight to donor sperm because this is very important for me. We can try to have a TESA, we can try to fix the [unheard] sperm for them, and we can try to have a cycle. Sometimes we have good results with this, but they need to know that the quality of the cycle is not going to be the same with the TESA sperm as with a donor, but knowing this, they can make the decision and they can go ahead with the TESA.
We freeze only MII because we know that it‘s like the mature and competent eggs. We strip the eggs two hours after the pickup, then we freeze all the MII ones. If we get some MIs, we wait another hour, we check them again, and if they are mature now if they turn into MII, we‘ll freeze them, and then we wait. If they are still MI, we wait for another hour, and we are going to do, we‘re going to check them every hour until six hours maximum to see if they have turned into a mature egg.
In case they’re mature, we freeze them, but if six hours after, they are still in MI, we don’t freeze them because we have seen that when we thought they were not going to be mature, and this gives really bad results. So, we think that there’s no point in freezing these in mature eggs because they are not mature; they haven’t completed the genetic cycle, so we can work with them.
Donors are not paid per se, like when you get your donor you get paid. They receive something for the hassle I think, it‘s not big money, I’m not sure about this actually, but they pay them because they need to take a taxi, they need to come, and for the hassle. It‘s not that they have a lot of money.
Motivation can be many of them. Some of them know couples that they have been through an IVF cycle and they needed donors’ eggs, so it‘s like okay if I can help people and it‘s not to be a bad thing for me, they’re going to compensate this hassle, is like why not? We find a lot of donors and the motivation is that one.
Maybe this question is better for the team, but it‘s a good question because in Spain we have a lot of donors. I don’t know why; for example, I know that we donate all kinds of organs a lot. It’s like we have this in mind that is like, ‘I’m not going to need this, so it‘s okay if I give them to someone else.’ I think it‘s a good thing because a lot of patients need donor eggs so, and then they can help them.
And how do the clinics find them? There are some adverts, but I think it’s mostly speaking, someone tells them that this clinic is good to go there and they go to the clinic, and if they are happy they come back.
Yes. If you’re going to freeze on day-3, and sometimes they are quick embryos and they feel already a morula, this is not a problem. Plus, when you freeze them, they decompact so you can see the cells again, so it‘s not a problem because you’re freezing it is going to be again on a cleavage stage.
Our clinic I think it was 45, always with PGS, but it was 45, I think. 44, 45, I will say 45.
