A Step By Step Guide To The IVF Process: Step Six -- Embryo Development

Blastocyst
 

Dear Readers: This is the sixth part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will continue to be posted over the next few weeks in installments. (For earlier installments in correct order scroll down to the beginning of July 2012.)

STEP SIX: EMBRYO DEVELOPMENT

At this point, we have gotten the eggs out of the ovaries, put them with the sperm or injected the sperm into them and fertilization has occurred. Each of these steps has lead to a decrease in numbers from the original number of follicles. Not all the follicles had eggs retrieved from them, not all of the retrieved eggs were mature and therefore could not be fertilized, and not all of the mature eggs fertilized or fertilized normally. So now we are left with a cohort of embryos that have fertilized normally and are ready to grow and develop into embryos that can be transferred.

At the end of fertilization, normal embryos are in a 2PN stage, or two pronuclei and is one cell. These are placed into special media that provides the proper nutrition for these early embryos to grow and develop. This is key for the growth of embryos. Embryo culture media has been researched and developed over the evolution of IVF technology, researching and finding the proper combination of chemicals to mimic the intratubal environment. In the natural process, the embryo is within the tube and develops and divides as it makes its way down toward the uterine cavity. So the culture media has to match the media that would be found within the tube. In addition, the environment, such as gas ratios and temperatures, have to match as well. So the requirement for embryo development is to have the proper nutrition within the Petri dish, the proper temperature within the incubator and the proper gas mixture within the incubator as well. Also, the embryo needs to be protected from airborne contaminants outside of the incubator. These factors are so critical that they will influence the success rates of an IVF clinic.

Many embryology labs, such as mine, are designed and constructed to the standards of a “clean” room, such as that used in Silicon Valley for making silicon chips. The airflow within the room is isolated. In other words, the airflow is completely separated from the air outside of the room so that there is little contamination from in the outside. In my lab, the airflow is set to be a positive flow, meaning the air pressure within the room exceeds the pressure outside the room so that when the door is opened the air pushes out rather than allow the outside air to push into the lab. In addition, the airflow within the lab is cleaned by a HEPA filter and Charcoal filter to filter out small particles and chemicals, called VOC’s or volatile organic compounds. VOC’s are the fumes or gasses you can smell after a room is painted or a road is repaved, but there are VOCS’s that can’t be smelled as well. These chemicals can kill or injure embryos so that they don’t continue their development. Finally, the embryology lab temperature must be maintained so that when the embryos are taken out of their warm environment to be checked, their temperature does not drop abruptly. When choosing an IVF clinic, it would be wise to ask about their lab set up and, if possible, tour the lab to see how well the environment is. Many centers have certification by the College of American Pathologists (CAP) which means they have undergone a survey, which includes evaluation for many of the aforementioned criteria for labs, and have passed and received certification of their lab.

If all of the above quality controls are in place the embryo can proceed with development to a stage where they can be transferred into the uterus. The embryo actually can be transferred at any point in its development, but time and research has identified the two optimal embryonic ages as day #3 or day #5. These are the two ages that most IVF centers in the world use in their transfer protocols.

So, by the day after fertilization (48hrs after retrieval) has taken place, the embryo has developed into a 2-4 cell embryo, in normal development. Sometimes embryos will have progressed further than 4 cells but that can either be because the evaluation of the embryo was later in the day (48hrs) or the embryo is developing faster than expected, which could be an indication of an abnormal embryo. Embryos are also examined for external features and a grade is given. There is no universally accepted standardized method for grading but they are all essentially similar. They are all based on the external or “morphological” characteristics of the embryo as viewed through a microscope. Almost all labs will count the number of cells that the embryo has on that particular date, up to the Morula stage where individual cells are no longer visible. They will also give it a grade (A,B,C or 1,2,3) based on the clarity of the embryo. That is, the amount of fragmentation or debris located within the cell. These fragments are pieces of tissue that have been extruded in cell division. Although cells with high amounts of fragmentation have been related to decreases in pregnancy rates, that is not an absolute. I have had the worst looking embryos lead to pregnancy, as have many other clinics. But, we know that most successes come from cells that either don’t have any fragmentation or a minimal amount. Finally, most clinics will look at the symmetry of the cells; do they look fairly equal or are there larger and smaller cells. In my practice, we use a simple 1,2,3 grading system where the embryos are evaluated for fragmentation and symmetry, and the combination of those two factors lead to a grade. Some clinics break these down and give two grades for each embryo; one to represent fragmentation and one to represent symmetry, and some use letters instead of numbers. In 2010, the Society for Assisted Reproductive Technologies released guidelines for grading embryos in the hope of standardizing this among IVF centers within the United States. In their system, cleaved embryos (those before morula stage) are evaluated for the number of cells present, fragmentation (0%, 1-10%, 11-25%, >25%) and cell symmetry (perfect, moderate asymmetry and severe asymmetry). Embryos are then given a score of Good, Fair or Poor.

The biggest disadvantage of current embryo evaluation methods is that it is essentially a beauty contest, so as I explain to my patients, Grade A or 1 or Good is “beautiful”, Grade B or 2 or Fair is “average” and Grade C or 3 or Poor is “ugly.” We know that most pregnancies come from Grade 1 or 2 embryos and only Grade 3 embryos have a decrease in pregnancy rates. This method does little to evaluate the internal quality of the embryos, which we know is really the main determining factor for embryo health or viability. That technology is yet to be developed. Embryo chromosomes can be determined by removing one of the cells and checking for its chromosomes, a procedure known as Preimplantation Genetic Screening (PGS/PGD), but this still does not evaluate the structures within the cytoplasm, or outside of the nucleus where the chromosomes lie, which are the structures that provide the energy for the embryonic cell. When looking at embryos to decide which to transfer, not only must the embryo appearance be taken into consideration, but its development rate must be considered as well, as an indirect measurement of embryo health. I’ll discuss this decision more in the next step.

To summarize the stages of development, at 24 hrs after egg and sperm have been put together (day of retrieval), the embryo is a 1 cell 2PN; at 48 hrs (Day#2) it is 2-4 cells; at 72 hrs (Day#3) it is 6-8 cells; at 96 hrs (Day#4) it is usually a compacting Morula; at 120hrs (Day#5) it is a Blastocyst. There is some variability to this development scheme as embryos do have differences in rate of division. In a natural (non-IVF) cycle, the embryo is usually at the Blastocyst stage when it reaches the endometrial cavity. In IVF the transfer is done either on Day#3 or Day#5. Because of the political pressure to do more single embryo transfer cycles, or 1 embryo transfers, many clinics are now culturing to Blastocyst stage before doing the transfer. This is because culturing to Blastocyst stage leaves less embryos to choose from and MAY indicate a healthier embryo, but the latter conclusion is not an absolute.

In my center, I have specific criteria to determine whether or not to proceed to Blastocyst. One of these criteria is that there has to be a minimum of 8 good quality embryos (7-8 cell, grade 1) because I know that many embryos will not make it to Blastocyst, and that is not necessarily because the embryos are bad. In doing PGS, I have seen Blastocysts turn out to be chromosomally abnormal embryos whereas an embryo that did not survive to Blastocyst had normal chromosomes (PGS usually is done with Day#3 embryos and takes two days to get the result so by the time the result comes back, the embryos are Day#5). I have also seen ugly poor looking embryos (4 cell, Grade 3) lead to pregnancies when transferred at Day#3 that would not have survived to Blastocyst. My reasoning is that Blastocyst culturing is not a perfected technology yet. A clinic that puts only a few embryos at risk to develop to Blastocyst is basically risking the cycle by not having anything to transfer. For that reason, I want to make sure that there are enough embryos to start with so that there will be embryos to transfer. In addition, it is still my personal belief that the uterine cavity is a better culture environment and media than what we have available in the lab. For this reason, most of my transfers are on Day#3, but I have colleagues who now transfer mainly Blastocysts. So, when looking at these transfer options with your doctor, ultimately the decision has to be made based on pregnancy rates at Day#3 vs Day#5 transfers and not just because you only want to transfer 1 embryo.

In the next entry we’ll discuss embryo transfer and the decisions that go into this step, as well as, the critical parts of the transfer technique.We will continue this discussion soon with the next installment, "Step Seven: Embryo Transfer". Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA
http://www.montereybayivf.com/

Patient Fails One Fresh, One Frozen IVF Cycle: Will Another FET Work?

Hello,

My name is S. from Boston. I am writing with a question regarding what I am going to be undergoing next week, a second frozen transfer. Just to give you some history, I had a first attempt successful IVF (in vitro fertilization) cycle in 2008 and delivered a healthy baby. We are now trying for baby #2 and had an unsuccessful fresh cycle, and an unsuccessful frozen cycle in the last few months. I still have several frozen embryos so my insurance is mandating that we use them prior to doing another fresh cycle.

I know the success rate is lower with frozen embryos but I wanted to know another opinion, if I should proceed with a fresh cycle if this one is negative. I have 3 frozen embryos left, that are all 6 cell and high implantation potential. I am not optimistic that this one will work, because the other two cycles they put in 2 8 cells and they didn't take. My doctor says there is no difference between 6 and 8 cell embryos, but if that is the case, then why do they always choose to transfer the 8 cells first? I know I could also lose some cells in the thawing process, so does that lower my chances more, and are there are risks associated with the baby, if I do become pregnant this cycle? Thank you so much!

Answer:

Hello S. from the U.S.,

These are very good questions that you should direct to your doctor. It is his/her responsibility to keep you informed.

Let me take the easy questions first. The reason why we use the 8 cell embryo first is because embryos are graded based on their appearance. Yes, that is we give them a higher grade, the better they look, just like a beauty contest. The cell number is the number of cells the embryo has divided into by that particular day, which I presume to be post-retrieval day#3. Again, we prefer embryos with more cells than less cells. That does not necessarily mean the embryos with more cells are BETTER than the embryos with less cells. In fact, preimplantation genetic testing often shows the opposite. So a higher number of cells does not guarantee a good embryo. The factors that make a good or perfect embryo are not things that we have the technology or knowledge to apply at this point in time. Maybe in the future. My preference is for my embryos to be between 6 cells and 8 cells at this point. Most pregnancies will result from embryos within this range, either grade I or grade II.

Frozen embryo transfers have a lower pregnancy rate probably because the lesser embryos are left to be frozen and the better embryos are transferred fresh. Also, it may be because of the freeze and thawing of the embryos, but the technique has gotten so good that I don't think that is much of a factor any more. But, that does not mean that a frozen embryo can't implant and produce a good pregnancy. I would still recommend that you use them first before another fresh cycle because the medications required are less, AND there are some studies that show that implantation is better if there is no ovarian stimulation, as in Donor cycles. That might be an advantage. You just have to hope that the embryos are still good enough.

I might suggest that you ask your doc to culture the embryos remaining to blastocyst stage. That will be a further validation of the embryos, and may lead to fewer embryos to transfer, but they will be at a stronger stage. That does not necessarily give you a better chance at pregnancy, but the assumption is that if the embryo can survive further culturing then it has a better chance of continuing to implantation. That way, you can further screen the remaining embryos that you have. The ones that don't make it to this point will be discarded, then you will need to move to a fresh cycle. If you have extra blastocysts, you should only transfer two max at this stage, they can be frozen and are in a better stage for the freezing.Finally, there are no added risks for a normal baby if by frozen eggs or embryos. If the embryos are abnormal they usually will not work (implant) or will end in miscarriage. You have not given your age, but this can be a factor in terms of embryo quality, success and genetic risks as well if you are 35 years old or older.

Good luck,

Edward Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A

Grading Of Embryos At Blastocyst: How Does It Reflect Implantation Rates?

Question:

My husband and I recently went through our first IVF. We have been trying for 2.5 years to get pregnant and have done 6 failed IUIs. We have stage 2 endometriosis that was cleared out by a laparoscopy last Fall. Aside from that we are unexplained infertility. We retrieved 10 eggs and 9 fertilized naturally. We transferred 2 blastocysts on Day 5 that were graded 2BB and 3BB at transfer. We had 5 others that made it to freeze on day 6.

I have been a little stressed out about the quality of the blastocysts. I know that 4AA is the highest. Will our blastocyst quality impact implantation rates? R. from the U.S.

Answer:

Hello R. from the U.S.,

The answer to your question is yes and no. It is ambiguous because grading does not necessarily predict whether implantation, pregnancy or a successful delivery will take place. I have often been surprised when I get a pregnancy from embryos that are "graded" as poor quality. I have also seen cases where when we do genetic testing called PGS (preimplantation genetic screening) the test results reveal that the good quality embryos are abnormal and the real bad one is normal! So I don't think you can say that the way your blastocyst are graded will necessarily have any impact on their ability to implant.

At this point in time, we do not have the technology to evaluate embryos fully to know which ones will implant and which ones won't. As far as I'm concerned, all embryos have the potential to implant and lead to a successful pregnancy. In my opinion, only God knows for sure. It is a good sign that you had embryos to transfer and freeze...Good luck with your transfer results!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Woman In Tasmania Has Done 14 IVF Cycles At One Center And Now Faces An FET: What Advice Can You Give Me?

(**If the blog-talk radio starts up, go to the October 1st blog post below & pause it...I will be keeping the show up for the month of October.)

Question:

Dear Dr Ramirez,

Someone wrote a comment on my blog suggesting I ask you. Basically, I was asking what questions to ask my RE. This is the post she was responding to:

Here’s where I am: I’ve been doing IVF/ICSI since July 2006. We started because my husband had a vasectomy many years ago, so it’s not like we’d been trying for years and didn’t know what was wrong and needed a diagnosis. We knew we’d need IVF if we wanted any hope of having a child.

I live in Hobart, Tasmania. There’s one clinic with only 2 REs: one who is part-time (he’s mainly an obsetrician) and one who is full-time. We started off with the part-timer but have been with the full-timer for a few years now. I would say they pretty much don’t have individualised treatment. They have a few standard protocols, but mainly seem to pride themselves on keeping treatment costs low so patients can have many cycles. Quantity, not quality. If you have repeated failures, they don’t do investigations; they just suggest you keep on going on.

To go to another clinic would cost us money, time, more stress, and be logistically difficult. That’s not to say I’m not up for it if need be. However my husband gave me the ‘I’m tired of treatment and would rather not pursue it, but I’m doing it for you’ bombshell the other night. So I don’t know if I could drag him by the testicles to an interstate clinic to try to get different treatment. I’m willing to go without him though. Having a child has become muchmore important than my marriage.

The only investigations I’ve had are a laproscopy, hysteroscopy, hydroscopy a couple years ago (I had endo, which was removed, and the hydroscopy as inconclusive as fluid didn’t move through my tubes but they looked OK). My obstetrician ordered a bunch of blood tests after Blobby’s miscarriage: protein C, protein S, AT 3, Anticardiolipin antibodies, LAC, Factor V Leiden, Prothrombin G20210A mutation MTHFR C677T mutation, MTHFR C677T mutation, and Karyotyping.I find it unbelievable that after so long, they still don’t try to find out WHY we’re having the problems we’re having. They never check hormone levels (not even during stim cycle – he just relies on ultrasounds to tell him what’s happening), they don’t check for implantation issues, there’s been no renothing. Hearing about the testing that goes on in other clinics has really opened my eyes. I would welcome finding out I had a problem because then we’d know whether it would be likely to be able to be fixed or if we had no hope.

Questions I’ve come up with are:

1. As one of our embryos is a 3 day and the other two are 4 day, can the 3 day be thawed used this time and thawed a day ahead? That way if it doesn’t thaw we still have 2 more we can attempt thawing.

2. Is there a wait list for donor semen? (There wasn’t a few years ago when I did 7 DI/IUI cycles, but I think there is now. Want to know just in case.)

3. Might DHEA help my embryo quality?

4. Any news on the egg donor wait list (Australia's)? (This is probably a stupid question; I know other women in Australia on the wait list and we all seem to get difference answers to our questions. Someone who is 27 was told recently she should have a donor by January 2011 – sorry, but that’s a HUGE porky she’s been told!)

5. The best embryo we’ve had was from a down regulation cycle. Is this just a coincidence, or should be try down regulation cycles again?

6. What sort of implantation failure testing can be done?

If you are interested, my blog "Riding The IVF Roller Coaster" is at http://tasivfer.wordpress.com/. I am writing from Hobart, Tasmania, Australia. Australia's island state - and a long way from any clinic other than the one I've been with for soooooo long. . .Cheers,TasIVFer

NOTE: As of 2012, TasIVFer is a MOM! "After 4 1/2 years, 14 fresh IVF cycles, 7 donor inseminations, 4 FETS, and the loss of my dear son Blobby at 14 weeks 2 days, we tried (half) an egg donor. Blood test 10 December 2010 = BFP. Little Spark was born 6 August 2011!!! He LIVES! Now the journey continues with an FET in November 2012 with our last embryo. Perhaps our last ever?" Good for her!!!

Answer:

Hello TazIVFer from Australia,

Let me take your questions in sequence and answer them the best that I can.

1. The Day #3 frozen embryo certainly can be thawed and cultured to align with the Day #4. My recommendation would be to thaw both, one day apart, and allow them to culture to blastocyst if your home lab has that capability. That may give the embryos a better chance of implantation. You don't mention what the cell # and grade was at the time of freezing but that is an important factor. As the saying goes, bad in-bad out. That means that if the embryo is poor quality, culturing further does not make it better quality. It may not survive the culture.

2. I cannot answer your questions regarding donor sperm wait lists. In the U.S., there are no donor sperm wait lists. Donor sperm are readily available. I guess that's because there are more men in the U.S. than Australia.

3. DHEA will do nothing and is not recommended. However, I would recommend that you consult my blog where I addressed the issue of implantation failure. I do have my own, specific protocol that I use for patients that fail IVF. Because I don't have any precise information from your cycles, I cannot give any specific recommendations.

4. Again, no egg donor wait lists in the U.S.

5. Coincidence probably but I would have to look at your cycle information to do a detailed analysis.

6. There are no specific tests for implantation failure.

I hope this answers your questions adequately. It is unbelievable that you have gone through so many cycles. I don't know of many women and their husbands that could manage the stress and frustration of prevailing through IVF for so long. I wish you the very best of luck with your FET cycle!

Keeping my fingers crossed! Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

45 Year Old Danish Couple On Sixth IVF Attempt: Should They Alter Meds & Blastocyst Transfer?

Question:

Dear Dr. Ramirez,

We are a 45 year old couple from Denmark on our sixth IVF attempt. The first three attempts produced 5/5/9 eggs with 225-275 units of Gonal-F and a fertility rate of 100%/60%/60% respectively. Eggs for transfer were three 8-cells on try one on day three, two 8-cells and one 10-cell on try two on day three and two morulas and a 10-cell on the third attempt on day five.

We then increased Gonal-F to 375 units and got 12 and 13 eggs in the next two attempts and a fertility level of 85%-100% and decided to go for Blastocysts and had two BC's and a Morula in the fourth attempt on day six and one BC and a Morula transferred the last time on day six. On the recent attempts we've been supplementing with Ovitrelle prior to aspiration (as well as folic acid, acupuncture and considerate food and no alcohol of course). After aspiration a dose of 16mg Medrol was administered for four days, then 8mg and then 4mg, as well as 81mg of Aspirin for the duration.

Our questions are: 1)should we continue to go for Blastocysts for transfer, and 2) do you have any suggestions as to an altered protocol perhaps in terms of increasing the dose or frequency of Medrol or any other meds that might help us?

Thanks in advance for your reply. T. From Denmark

Answer:

Hello T. from Denmark,

The good news is that your wife's ovarian response is still good and strong. She has done very well on her current stimulation protocols. The problem that you have is not so much the external quality of the embryos formed, they have been good, but the internal quality of the embryos. We know that with age, the quality of the eggs and thus the embryo quality deteriorates. That is probably what is leading to your failure. We rarely see pregnancies after the age of 43 in a woman using her own eggs. However, there was a case in New York of a woman who was successful at 49 years old, and is currently the oldest to become pregnant with her own eggs using IVF. It did take her two and 1/2 years of trying, however. Statistically, your chances of pregnancy with IVF are less than 1% per attempt based on age factors alone.

In terms of whether to do D#3 or D#5 transfers, I don't think it makes any difference. One is not better than the other. The embryos that would make it to blastocyst would still have done so in the uterus. In fact, I think the uterus is a better culture environment than the lab. I generally transfer at D#3 for this reason. In fact, in your case if you were my patient, I would transfer ALL embryos back on D#3 to maximize your chances.

In terms of what other protocols, I use Medrol starting at the beginning of the cycle (D#2) taken as 16 mg until the transfer then decreasing to 8 mg thereafter. I stop with the pregnancy test. I also use aspirin 81 mg per day starting at the beginning of the cycle and heparin 2000 units twice per day injections starting at the beginning of the cycle. I also use a "mixed" protocol of Gonal-f or Follistim + Menopur/Repronex for a total FSH dose of 600IU to start. In most cases, the patients stay at that level but some will decrease based on their response. In your case, your wife does not need more meds since she stimulated well, but a mixed protocol might be advised.

Your only option is to keep trying or move to donor. I am amazed that you have done so many cycles already. Most in the U.S. will not do that many cycles due to cost issues.

Good luck with this upcoming cycle & never lose sight of your goal...it can be achieved if you are open to options.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Male Factor Infertility -- IVF Cycle FET Positive But Ended With Miscarriage: Should I Seek A Second Opinion?

Question:

Dr. Ramirez,

My husband and I are a 29yo healthy couple with male factor infertility. Motility is less than 1%, morphology is about 25-30%, and count is pretty low-normal. There are no female issues. We have done 2 IVF/ICSI cycles and one FET (frozen embryo transfer). The first IVF (in vitro fertilization) cycle, I was mildly hyperstimmed. The egg quality wasn't great, and we had about a 50% fertilization rate. We transferred 2 grade A embryos that did not result in pregnancy. No embryos made it to day 5. IVF #2 was much better and had an 80% fertilization rate. 2 day-3 grade A embryos were transferred, but there was no implantation. There were 2 day-6 blasts that were frozen. Both were starting to hatch upon thawing, and the FET resulted in a singleton pregnancy with a heartbeat at about 7 weeks. Unfortunately, I miscarried (no heartbeat) at 8 weeks.

My question to you is when should I seek a second opinion? We had planned on obtaining a 2nd opinion if the FET was unsuccessful, but we feel like technically it was successful. We like the place we go to right now and feel that they are familiar with us. We are planning to do IVF #3 in the near future and are torn as to whether we should stay here or move on. If we stay with the current practice, we will not be changing the protocol since it was successful last time. Although it has been suggested, we are not ready to use donor sperm since we were able to grow 2 blasts and achieve a pregnancy. We are located in Missouri.

Thanks in advance for your time.

Answer:

Hello L. from Missouri,

I agree with your statement that technically the FET was successful. In fact, the FET cycle WAS successful. Remember, IVF can only give you the opportunity to become pregnant. It cannot MAKE you pregnant because the last two steps in the natural process, embryo hatching and implantation, are NATURAL steps and we don't have the technology to make that happen. So, the fact that an embryo did those two steps and the pregnancy went to 7 weeks is a success. And, it is a very good sign because it now shows that what you are doing can work!

I would not give up on that clinic yet. In fact, pregnancy rates with FET are lower than fresh cycles, so a success with an FET is good. They deserve the credit. Now that they have stimulated you twice, know how you react, etc., they are hopefully in a good position to build on that the next cycle. You have to give them some credit for that.

Overall, I would hang in there. You've proven that it can work. Whether or not the pregnancy continues is solely and completely dependent on the embryo. It was probably an abnormal embryo. Now, you just need to get a good one there and you'll go all the way. Don't look back, just look forward. You should now be more encouraged than before because you know that it can work. It is just a matter of time!

On a personal note, I have a patient that I was able to get pregnant on her first try at the age of 36 and she had a beautiful child. She just came back to me for her second child at 39 (worse chances statistically) and became pregnant again, but it was an abnormal pregnancy and ended in a miscarriage. I found out today, that she is planning to transfer to another clinic because they have a "special" research program going on that gives patients a significant discount. You can't believe how heart broken and how I feel rejected by this. I put my heart and soul into my patients, and they get the best care that they can receive. I know that logically the cost is a significant issue, and this is what is driving the patient, but having gotten so close to a success, when we have been successful before, is difficult for me. That is what your clinic will think too. They'll ask themselves, "why is she leaving when we were successful under less odds?"

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Comment: Dr. Ramirez clearly stated his opinion and seemed to have genuine answers. I appreciate his advice and his providing this service

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions

Question:

Hello again, this is S. with some follow-up questions from my earlier email.

Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!

Answer:

Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

IVF implantation failure

Questioner: Sophie
Subject: IVF implantation failure; luteal phase brown spotting, even with high progesterone levels Date

Question:
Dear Dr. Ramirez,

I have found your responses to others extremely helpful!

I am 35 years old and am writing from Hungary. My husband
and I've just finished our second, unsuccessful round of IVF
with ICSI; both were 5th-day transfers with a good quality
pair of embryos in each. My husband had had two samples
frozen before his BMT several yrs ago, which is what we used
for the IVFs--it looks like now he occasionally has a
nonmotile cell or two, but not much else.

I would very much appreciate your thoughts and advice on
luteal phase issues, including luteal phase support during
IVF, given a potentially short luteal phase and pre-cycle
brown spotting.

The first round of IVF, I got progesterone suppositories,
but my prog. level was fluctuating with that (was as low as
18.85 9 days post-transfer, and was up to 43 3 days later).
As a result, bleeding started 7 days post-transfer.

For the second IVF (with frozen embryos), I got progesterone
injections instead, which kept my prog. level up (56, 65).
Nonetheless, I still had definite brown spotting starting 4
days post transfer, gradually turning rust-colored. Both
transfers, I had mild cramps on days 2 and 3 after the
transfer.

As we were making preparations for the IVF, my fertility
doctor determined that I have a relatively short luteal
phase despite the fact that my cycles are 28-31 days long: I
ovulate on the 17th-21st day (20th is typical). In addition,
for the past three years, my period has always been preceded
by 1-4 days of brown spotting. And *including* those
spotting days, my luteal phase has been 9-12 days long
throughout 2009 (13 days when I was on Suprefact for the
ovarian stimulation).

A further detail that could be relevant: I have an
autoimmune thyrod disorder that is being monitored, no
medications for it. My anti-TPO level is 1516 and I have a
thyroid cyst about 3x2x3 cms in size, the biopsy was
negative. My thyroid levels have been normal: TSH 0.65-1.2,
T4 15.6.

Any thoughts on what might be behind the persistent pre-
cycle spotting, despite the high prog. levels with the
injections, and what can be done about it?

I would like to do all I can to exclude the possibility that
the embryos did not implant because of a luteal-phase-
related issue, especially because the number of chances
we've got are limited. Do you have any suggestions what
might be worth asking about, any variations on the protocol,
any further tests? Right now, the plan is to do the 3rd IVF
round--with potentially the last batch of frozen sperm--with
the same luteal phase support as before: ovitrelle for the
ovulation and prog injections, following a stimulation phase
consisting of suprefact and gonal-f 150. I am told that
based on my low HCG level ( 0.1) measured at 12 days post
transfer, the embryos did not even begin to implant in
either of the previous rounds. So the spotting in this
second round wasn't due to implantation then.

Also, I have read about taking vitamin B6 for luteal phase
defect, my doctor here says he doesn't know about that
helping with the short luteal phase and the spotting. What
are your thoughts on the matter?

I very much appreciate your time and help.
Yours sincerely,
Sophie

Answer:
Hello,

Thank you for all the information and the very well written letter. I can't even tell that you are from Hungary. Your English is perfect!

First of all, despite the fact that you may have had a luteal phase defect in the past, the purpose of the progesterone after retrieval is to treat for possible luteal phase defect. Therefore, you don't have a luteal phase defect with your IVF cycles, and this is NOT the reason for the implantation failure. Something else must be going on. You don't mention the quality of the embryos, but that would be one question. Also, you don't mention how many were retrieved, how many fertilized, how many did not make it to blastocyst and how many were frozen. I presume there were none to freeze since you don't mention it.

Implantation failure is a difficult problem because we are not able to distinguish all the processes required for implantation, and there are not tests to help. The only current test available, b-Integrins, don't help because the treatment is to use more progesterone. I would do that any way. Please read more on implantation failure and recurrent miscarriage here: "Recurrent Pregnancy Loss".

My approach to patients with implantation failure is to add the following medications:

1. Aspirin 81 mg per day beginning at the start of the cycle.
2. Heparin 2000 units twice per day beginning at the start of the cycle.
3. Medrol 16 mg daily until transfer then 8 mg from that point until positive pregnancy, then stop.
4. Increase progesterone to 50 mg injection plus Endometrin 100 mg twice per day vaginally. The injections starts on the day of the retrieval and the suppositories start the day after the transfer.

This regimen covers most immune responses that might prevent implantation, as well as, any micro-clots that form at the site of implantation. It is used mainly in patients that have recurrent miscarriages, but has proved useful in IVF as well. You might want to suggest this to your doctors. This regimen is unproven and controversial, however. Another suggestion would be to transfer at day # 3 instead of going to blastocyst. Blastocyst culturing is not perfected, and I still believe that the uterus is a much better culture media and incubator that the lab.

Also keep in mind that pregnancy rates are very clinic dependent. There is a wide variety of pregnancy rates between clinic, and the rates can very much be influenced by the laboratory environment, the physician skill doing the transfer and the stimulation and culture protocols. One option might be to try a different clinic. I recently changed my clinic location and our pregnancy rates are much better than before because we were able to build a better facility.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/

Monterey, California, U.S.A