Q: When does the embryo transfer procedure occur?

Embryos are generally transferred to the woman’s uterus at the 2-8 cell stage. Embryos may be transferred anytime between day 1 through day 6 after the retrieval of the egg, although it is usually between days 2-4. Some clinics are now allowing the embryo to reach blastocysts stage before transferring, which occurs around day 5.

Q: Fresh & thawed embryos to transfer?

Embryo transfer refers to a step in the process of assisted reproduction in which embryos are placed into the uterus of a female with the intent to establish a pregnancy. Embryo transfer is a simple procedure that follows in vitro fertilization (IVF) and is often considered the simplest and final step of the in vitro fertilization process. The objective of embryo transfer is to facilitate conception following fertilization from the in vitro fertilization procedure.

Q: Fresh or frozen thawed embryos to transfer?

Newborns from the fresh ET group had lower birthweight than the frozen-thawed ET group. Embryo aneuploidy is likely the leading cause of implantation failure in IVF cycles. There is well-documented evidence of increasing maternal age directly correlating with an increase in embryonic aneuploidy rates ). With recent advances in IVF (extended embryo culture, trophectoderm biopsy, and vitrification) along with the combination of new and advanced technology in preimplantation genetic screening (PGS) ongoing pregnancy rates (PRs) have improved with the selective transfer of euploid blastocysts . Preimplantation genetic screening is routine in some clinical IVF practices in the United States. The two transfer strategies for euploid embryos currently in clinical practice are to use vitrified/warmed (“freeze-all”) or fresh embryos for the first ET. The freeze-all strategy involves cryopreservation of all embryos after biopsy, and then waiting for the PGS results of the whole cohort (day 5 and day 6 embryos) in preparation for a frozen ET. The fresh strategy involves biopsy of expanded blastocysts before 10 am on day 5 and cultured overnight to await PGS results for a fresh ET of euploid embryos before noon on day 6. In this scenario, slower growing embryos may be biopsied on day 6 and frozen for later use. There are benefits and challenges to each approach. There is evidence that implantation and clinical ongoing PRs may be higher when transferring vitrified/warmed embryos in a non stimulated cycle compared with fresh transfer in a stimulated cycle. The incidence of low birthweight babies and preterm delivery has also been shown to be lower in pregnancies resulting from frozen transfers compared with fresh transfers.

Q: What is IVF?

In Vitro Fertilization is an assisted reproductive technology (ART) commonly referred to as IVF. IVF is theprocess of fertilisation by extracting eggs, retrieving a sperm sample, and then manually combining an egg and sperm in a laboratory dish. The embryo(s) is/are then transferred to the uterus.

Q: Gender selection

This is a procedure which is done by genetic screening of the embryos before transfer. Contrary to the belief that laboratories can define %100 of the sperm gender before injecting them into the eggs they are chosen by embryologist without knowing neither the genetic structure nor the gender of them. Only after eggs are fertilized at day 3 or day 5 cell/ cells are taken from embryos by laser assisted biopsy and send to genetic laboratory to screen both the genetic health and the gender of them. After this if there is an embryo both genetically healthy and has the prefered gender then the embryo transfer can be done. Ethics should be cornerstone of every research and specified rules were regulated for protection of humans in biochemical and behavioral researches. Genetic research has largely improved since past two decades, but ethical issues in this research field are of a great importance in appliance of these researches. As the the Director of an IVF Clinic I am aware of all the ethical questions that gender selection raises and believe that this decision is not very necessary if there is no healt problem. The ethical basis for a decision to pursue sex selection takes into account the life that the child would have to endure, as well as the emotional, physical, and financial support the parents would be required to provide if a medical problem will be inherited by the child.

Question 1

Why progesterone support after IVF?

Accepted Answer

Successful implantation requires synchrony between a competent blastocyst and a receptive secretory phase endometrium. As estrogen rises during the follicular phase and a dominant follicle emerges, OVARIES produce P, which induces endometrial secretory transformation and promotes receptivity.

Fertility treatments may interfere with this production via several mechanisms. Ovulation induction (OI) may result in a premature rise of P and alterations in endometrial receptivity. Furthermore, supraphysiologic E2 elevation from ovarian stimulation may cause alterations in luteal phase (the phase after egg collection)  LH secretion. 
Supraphysiologic E2 levels are often associated with multifollicular development during assisted reproductive technology (ART).  The use of GnRH antagonists - Cetrotide/ Orgalutran - for pituitary down-regulation and mechanical disruption of follicles during oocyte aspiration may further affect luteal function.

To reverse this negative effect we give Progesterone support. Support after egg collection with exogenous P after ART is routine because it is associated with higher pregnancy and live birth rates.

Question 2

Adjuncts in the IVF laboratory

Accepted Answer

Globally, IVF patients are routinely offered and charged for a selection of adjunct treatments and tests or ‘add-ons’ that they are told may improve their chance of a live birth, despite there being no clinical evidence supporting the efficacy of the add-on.

Any new IVF technology claiming to improve live birth rates (LBR) should, in most cases, first be tested in an appropriate animal model, than in clinical trials, to ensure safety, and finally in a randomized controlled trial (RCT) to provide high-quality evidence that the procedure is safe and effective. Only then should the technique be considered as ‘routine’.

Embryo glue and adherence compounds

The use of fibrin sealants to reduce ectopic pregnancy rate and increase LBRs was first proposed by Feichtinger et al. (1990) Despite this early promise, treatment using fibrin sealants never demonstrated reliable significant improvement in clinical outcomes and more recently, the focus has shifted to the use of a specific embryo transfer (ET) medium enriched with the glycoprotein hyaluronan (HA). It is well reported that HA is naturally present in the female reproductive tract and endometrium and forms a viscous solution which could enhance the ET process and prohibit embryo expulsion The published data surrounding the use of adherence compounds are highly varied in quality and robustness of study design and as a result, the use of HA supplemented media for ET is still regarded as controversial, we don't prefer to use it .
Sperm DNA fragmentation

Many clinics offer all their patients a sperm DNA fragmentation test. The assays include TUNEL, Comet, SCD assay, SCSA and 8-OHdG test There are clear differences between assays in terms of the type of DNA damage being measured and their relative sensitivity . However, no particular assay has yet emerged as being of greater diagnostic value than any other. Ultimately, the purpose of such an assay is to indicate which treatments may be contraindicated for, or beneficial to, patients. This requires both diagnostic accuracy for the assay and evidence of effectiveness for the treatment(s).

The Practice Committee of the ASRM has concluded that ‘current methods for assessing sperm DNA integrity do not reliably predict treatment outcomes and cannot be recommended routinely for clinical use’ However, a recent Cochrane report observed that low-quality evidence suggests that antioxidant therapy in the male might increase Clinical Pregnancy Rates and Live Birth Rates in patients, where the spermatozoa are suffering from oxidative stress.

Time-lapse imaging

Taking pictures over time and reviewing them as a film, also known as time-lapse imaging (TL), is a technique that has been used for a century. Indeed, the first time TL imaging was reported as a tool to visualize early embryonic development was in 1929 . In that report, a remarkably detailed description of hamster embryonic development was described and the authors went on to speculate whether the observed timings in cleavage rate could predict ‘embryonic potential’. More than 50 years later, human embryos were filmed using TL technology during their first 3 days of development (Eriksson et al. 1981). The next significant breakthrough was the work by Payne et al. (1997) who used TL imaging to describe the first events during fertilization, thus providing insight into how diverse and dynamic early embryonic development can be.

The usefulness of Time Lapse imaging in human IVF has been well debated. Among the proposed benefits that have been put forward are:
 • not missing important events during culture 
 • quality control 
 • teaching applications 
 • more information to the patient an increase in LBR

Time Lapse imaging serves so many other functions in the laboratory that its introduction will not be held back. It may be unthinkable in 5–10 years to still only be observing embryos by manually taking them out and looking at them. TL imaging is a tool which confers a number of practical benefits to the IVF laboratory. The future challenge for TL imaging is to find the best role in the IVF laboratory and to reduce implementation and consumable costs.

Question 3

How many embryos to transfer?

Accepted Answer

A COMMITTEE OPINION

Practice Committee of the American Society for Reproductive Medicine
Practice Committee of the Society for Assisted Reproductive Technology

A. Patients with a favorable prognosis:

1. In patients of any age, transfer of a euploid embryo has the most favorable prognosis and should be limited to one.
2. Patients under the age of 35 should be encouraged to receive a single-embryo transfer, regardless of the embryo stage.
3. For patients between 35 and 37 years of age, strong consideration should be made for a single-embryo transfer.
4. For patients between 38 and 40 years of age, no more than three cleavage-stage embryos or two blastocysts should be transferred. In cases where euploid embryos are available, a single-blastocyst embryo transfer should be the norm.
5. Patients 41–42 years of age should plan to receive no more than four cleavage-stage embryos or three blastocysts. In cases where euploid embryos are available, a single-blastocyst transfer should be the norm.

B. Other scenarios:

1. In each of the above age groups, patients who do not meet criteria for a favorable prognosis may have an additional embryo transferred according to individual circumstances (Table 1). The patient must be counseled regarding the additional risk of twin or higher-order multiple pregnancy.
2. If otherwise favorable patients fail to conceive after multiple cycles with high-quality embryo(s) transferred, physicians and patients may consider proceeding with an additional embryo to be transferred.
3. Patients with a co-existing medical condition for which a multiple pregnancy may increase the risk of significant morbidity should not have more than one embryo transferred.
4. In the rare cases where the number of embryos or blastocysts transferred exceeds recommended limits, both the counseling and the justification must be documented in the patient's permanent medical record.
5. In women ≥43 years of age, there are insufficient data to recommend a limit on the number of embryos to transfer when the patient uses her own oocytes. Caution should be exercised as the risk associated with multiple pregnancy increases dramatically with advancing maternal age.

C.
In donor-oocyte cycles, the age of the donor should be used to determine the appropriate number of embryos to transfer. For example, when the donor is <35 years of age and other favorable criteria exist, single-embryo transfer should be planned.

D.
In frozen-embryo transfer cycles, favorable characteristics should be based on the age of the woman when the embryos were frozen and include the presence of high-quality vitrified embryos, euploid embryos, first FET cycle, or previous live birth after an IVF cycle. Embryo transfer numbers should not exceed the recommended limit on the number of fresh embryos transferred for each age group.

Question 4

When does the embryo transfer procedure occur?

Accepted Answer

Embryos are generally transferred to the woman’s uterus at the 2-8 cell stage. Embryos may be transferred anytime between day 1 through day 6 after the retrieval of the egg, although it is usually between days 2-4. Some clinics are now allowing the embryo to reach blastocysts stage before transferring, which occurs around day 5.

Question 5

Fresh & thawed embryos to transfer?

Accepted Answer

Embryo transfer refers to a step in the process of assisted reproduction in which embryos are placed into the uterus of a female with the intent to establish a pregnancy.

Embryo transfer is a simple procedure that follows in vitro fertilization (IVF) and is often considered the simplest and final step of the in vitro fertilization process. The objective of embryo transfer is to facilitate conception following fertilization from the in vitro fertilization procedure.

Question 6

Fresh or frozen thawed embryos to transfer?

Accepted Answer

Newborns from the fresh ET group had lower birthweight than the frozen-thawed ET group.

Embryo aneuploidy is likely the leading cause of implantation failure in IVF cycles. There is well-documented evidence of increasing maternal age directly correlating with an increase in embryonic aneuploidy rates ). With recent advances in IVF (extended embryo culture, trophectoderm biopsy, and vitrification) along with the combination of new and advanced technology in preimplantation genetic screening (PGS) ongoing pregnancy rates (PRs) have improved with the selective transfer of euploid blastocysts . Preimplantation genetic screening is routine in some clinical IVF practices in the United States.

The two transfer strategies for euploid embryos currently in clinical practice are to use vitrified/warmed (“freeze-all”) or fresh embryos for the first ET. The freeze-all strategy involves cryopreservation of all embryos after biopsy, and then waiting for the PGS results of the whole cohort (day 5 and day 6 embryos) in preparation for a frozen ET. The fresh strategy involves biopsy of expanded blastocysts before 10 am on day 5 and cultured overnight to await PGS results for a fresh ET of euploid embryos before noon on day 6. In this scenario, slower growing embryos may be biopsied on day 6 and frozen for later use.

There are benefits and challenges to each approach. There is evidence that implantation and clinical ongoing PRs may be higher when transferring vitrified/warmed embryos in a non stimulated cycle compared with fresh transfer in a stimulated cycle. The incidence of low birthweight babies and preterm delivery has also been shown to be lower in pregnancies resulting from frozen transfers compared with fresh transfers.

Question 7

What is IVF?

Accepted Answer

In Vitro Fertilization is an assisted reproductive technology (ART) commonly referred to as IVF. IVF is theprocess of fertilisation by extracting eggs, retrieving a sperm sample, and then manually combining an egg and sperm in a laboratory dish. The embryo(s) is/are then transferred to the uterus.

Question 8

Gender selection

Accepted Answer

This is a procedure which is done by genetic screening of the embryos before transfer.
Contrary to the belief that laboratories can define %100 of the sperm gender before injecting them into the eggs they are chosen by embryologist without knowing neither the genetic structure nor the gender of them. Only after eggs are fertilized at day 3 or day 5 cell/ cells are taken from embryos by laser assisted biopsy and send to genetic laboratory to screen both the genetic health and the gender of them. After this if there is an embryo both genetically healthy and has the prefered gender then the embryo transfer can be done.

Ethics should be cornerstone of every research and specified rules were regulated for protection of humans in biochemical and behavioral researches. Genetic research has largely improved since past two decades, but ethical issues in this research field are of a great importance in appliance of these researches. As the the Director of an IVF Clinic I am aware of all the ethical questions that gender selection raises and believe that this decision is not very necessary if there is no healt problem. The ethical basis for a decision to pursue sex selection takes into account the life that the child would have to endure, as well as the emotional, physical, and financial support the parents would be required to provide if a medical problem will be inherited by the child.

Question 9

What is MYOMA?

Accepted Answer

Myomas are the most common benign tumours of the uterus. They are present in up to 40% of women of reproductive age, and by the age of 50 years the estimate rises to an incidence up to 80%. Worldwide, myomas are the most common indication for a hysterectomy and therefore a major public health burden.
Although most women with myomas remain fertile, studies have shown that myomas are associated with infertility. This is partly based on the observation of myomas in women with unexplained infertility. Of all women evaluated with infertility, 30–40% are diagnosed with unexplained infertility. Among these patients, estimates of myoma incidence may vary from 2% to 12.6% . Additionally, a recent large cohort study in patients with uterine myomas showed an increased time to first and subsequent pregnancies compared with women without myomas.
Different fibroid characteristics may affect fertility in ways that are not completely understood. It is postulated that the main factor is that distortion of the uterine cavity by myoma may alter the receptivity of the intrauterine environment. This might be additionally influenced by the changes in functionality of the myometrium. Any of these alterations can consequently disturb the implantation of the embryo and may result in adverse reproductive outcomes.
Myomas are heterogeneous in location, size and number. The location of myomas in the uterus can be classified via the system of the International Federation of Gynaecology and Obstetrics FIGO;. The location of the myomas appears to be responsible for the size of the influence on reproductive outcomes. Previous research has found that women with submucosal myoma, compared with those with no myoma, have higher miscarriage rates and lower rates of implantation, ongoing pregnancy and live birth. On the other hand, subserosal myoma have no significant impact on reproductive outcomes, while the effect of intramural myomas ( myoma which is in the muscle part of uterus) remains debatable because of conflicting study results.

Op. Dr. Hakan Kozinoğlu

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