Let’s start with the first factor, which is an embryo. Embryo quality, we understand that we have also here two main factors, which will predict the quality of the embryo, this is the oocytes and this is the sperm, so we will look at the oocytes separately, and we will look at the sperm separately. So the oocytes are the main creator of the embryo, and when we are talking about the oocytes, we also have two main factors, this is the quality of the oocytes and the quantity, which I need to get the best success rate, so if you are talking about the quality what factors can influence the quality of our oocytes?
First of all, it is the age, we understand the age for women is the crucial factor because our biological clock is ticking every day, so every day, we are losing oocytes and we are losing the quality of our oocytes. During the fertilization, oocytes are dividing, and for this division, we need a lot of energy. If the oocytes are young, we have a lot of energy, and the division is correct. If the oocytes are older, we’ll have less energy, and you can have the problems with the division, we can have incorrect division. Sometimes, we receive the embryo, which can have chromosomal abnormalities. How age can correlate with our success rate.
If you are at the age of up to 35 years, statistically, out of our 10, oocytes 7, will be of good quality and will divide correctly, and only 3 of them can have some chromosomal abnormalities. If we are talking about 35-39 years, we call it like a gray zone. This means that we can have 50/50 chances, this means that half of the oocytes can have the right division, and the second half will have abnormal division. In the age range 41-42 years, we have 80% of abnormal division and only 20% of normal division. But over the age of 42, we can have catastrophic results, which means that only 2% of all our oocytes will divide correctly, but we understand that in women over 42 years, we have not, so high ovarian reserve and we need approximately 80 oocytes to have 2 embryos of good quality. This is just an unreal situation, this is very hard to receive, therefore, we always ask you to think about the maternity at the age up to 35, this is the best option, but in case you are at the age of 35 – 39, please think about your maternity, and if you are not planning to be a mother now, you can have the option to vitrify your oocytes and to have like a backup for the future maternity.
At the age of 42 plus, you can use your vitrified oocytes and have your own genetic children. The second factor which can influence the oocytes is stimulation protocol. Nowadays, we have stimulation protocols, the so-called short protocol with antagonists, and the long protocol with agonists. Just yesterday, I went through the new investigations that show the information that indeed there is no specific data, which confirms that one protocol is better than another one.
So if you are a good responder, you will be a good responder on each protocol. If you’re a bad responder, then we understand that the quantity of oocytes is not enough, and any protocol for you will not give you better results. The main factor in stimulation protocol is the administration of all medications, just like the doctor prescribed because sometimes it is a big stress for the patients because you need to take a huge number of new medications simultaneously. Some of them, you need to insert intramuscularly, some of them you need to insert subcutaneously, some medications are like tablets, so this is a huge stress for you.
Please, be very specific in the administration of the medication because all these can influence the quality of the oocyte, especially if you will miss the day of administration of the medication, this can influence our results. Also, some medications can increase the quality of the oocytes f. e. LH, which is the stimulating medication, they are beneficial for the patients who are over 35. If we are adding LH supplementation to the stimulation protocol, those patients can benefit from having a better egg quality. Also, if we are talking about the triggering, HCG triggering gives us a better result, we can have more mature oocytes, and the results will be of a better quality of our oocytes. It is very important to insert the trigger exactly at that time which is prescribed in your protocol because if you will miss the trigger, or you will postpone it, it can affect the quality of oocytes, sometimes very rare, but still, our patients are missing the day, or the time of the triggering, in that case, we can have much fewer mature oocytes or even preterm rupture of the follicles, and we can not receive the oocytes during the egg collection.
If we are talking about the quality, the first question is for sure what number of oocytes is adequate for our best success rates, so 12 oocytes are the optimal number of oocytes which will provide us at least 2 embryos of good quality, but if we are talking about the age, we can have morphologically good quality this means that when the embryologist is looking on the embryo, it looks good, but still, it can have chromosomal abnormalities inside, we can’t see them without special investigations, without special testing, which is called PGS, and sometimes we understand that our negative attempts in a patient who is over 42, even with the good quality means that the embryo was with chromosomal abnormalities and so how can we influence the oocytes, or what can affect the quality of the oocytes. First of all, this is AMH level, this is our predictor of the quantity of the oocytes that we will receive and antral follicle count before you start the stimulation, the doctor will monitor your antral follicle count and will monitor your AMH level and the higher AMH level you have, the higher number of oocytes we will receive at the egg collection. We understand that the AMH level is the marker of ovarian reserve, and it is decreasing with age. Age is a factor, not only for the quality but also for the quantity of the oocytes. Over the age of 40, we have extremely decreased levels of our AMH and our ovarian reserve.
The number of oocytes can be influenced by stimulation. If we start with a maximum dosage of stimulation protocol, we will receive a higher quantity of the oocytes. If we start with a minimum dosage of the stimulation protocol, we can not receive the maximum that we can out of our ovaries. Also, the technique used during the aspiration can influence the results. During the aspiration, we need to aspirate all fluids out of the follicle. Sometimes the follicles are hard to reach, and the doctor can miss the follicle and just can’t reach the follicle and this is also the parameter that, which can influence the quantity of the oocytes. In our clinic, we are using the flashing of the follicles. Especially, when we have fewer than 6 follicles, this means that sometimes the oocytes can be fixed to the wall of the follicle, and if you are just aspirating the fluid out of the follicle, the oocytes can stay in the follicle.
Therefore, we’re using the flushing, we insert the fluid inside the follicle called the liquid, we just flush the follicle, and then we will once again aspirate the liquid, and during this flushing, we maximize our chances to receive all oocytes that are in your ovaries. What to do if you have a few follicles or a few oocytes and decreased levels of AMH, how to increase our chances? In our clinic, we use so-called embryo banking, if you have 2 or 3 oocytes during the aspiration, your chances are approximately 40%. Out of 3 oocytes, we cannot receive the blastocyst, but if we fertilize those 3 oocytes and freeze them on the zygote stage, this means that we will freeze the embryo on the 1st day of their living. Then we repeat the stimulation, again receive several oocytes and fertilize them and cumulate several embryos f. e. at least 6, you will increase your chances of being a normal responder, and you can use your own oocytes, and you can increase your chances for a better success rate. Sometimes, if you have a poor quality of the oocytes, we can use the solutions for the cultivation, which are reached with additional ingredients for the better cultivation outcomes. If we have patients who have poor blastocyst rate f. e. out of 8 zygotes, we have no blastocyst, then for the next stimulation protocol, we analyze with the patient our future steps, we can change the protocol, we can change the stimulation medicine, and also we propose to the patient additional cultivation solutions just to give rich ingredients for better cultivation for the patients.
The second creator of the embryo is the sperm. If we are talking about the sperm, the first most important thing for the spermatozoa is the morphology. If you have good morphology of the spermatozoa, we will have the good quality of the embryo and what to do if the morphology is bad. All of our patients are undergoing consultation with a urologist. The urologist is working with a patient and is preparing for the IVF procedure. We understand that for the IVF procedure, we need only 10 or 11 spermatozoa or a maximum of 20 to 25, depending on the quantity of the oocytes, but still, we need them with good morphology, and the urologist is working hard to receive the good morphology of the sperm.
Sometimes we have the patients who, even after this treatment, they do not improve the results of the morphology. What to do in such cases? We started to do the TESE procedure, we are extracting the sperms out of testes, and in case, that in ejaculate we don’t have morphological normal spermatozoa or we don’t have any movement or active movement of spermatozoa, we are proposing to our patients extracting spermatozoa from the testes. This can increase our chances to receive a better quality of the sperm. We can also use the PICSI or IMSI method of fertilization, where we are selecting the best parameters based on morphological criteria and doing the ICSI procedure for the oocytes, this can increase our chances for the pregnancy.