Hi I wanted to post the results of our consult with our RE. It was amazing. Our RE showed us the sheet for the donor and said that our donor did hyperstimulate at the end of the cycle. The estrodail readings never reached 200pg/iui per follicle. Do you know which day the estradoil reading should max out and then do you stay at that level during the rest of the stimulation protocol?
Our Re stated that we had a fill in embryologist and the fill in embryologist graded the embryos harder than the other embryologist and that was the reason for our b- and also b. Our RE had used this embryologist before in past cycles and said this embryologist never graded any other couples embryos as an a grade.
Our RE stated also that the cells of the embryos was much more a predictor of success of a cycle versus the quality of the embryos.
I was shocked. It was amazing then the RE started attacking me as a paitent when I was asking her some questions that contradicted what she had said in the past. And that I was being unreasonable and she would waive her fees to transport our embryos to which ever clinic we wanted.
Lots of issues, but anyway, can embryologist vary that much in grading embryos and I thought it had to do with how fast the embryos divided.
She also said to unthaw all the remaining (6&8 cell embryos and take them to blastocysts, and I told her why then did we not take them to blastocysts to begin with. It was our understanding our clinic does not have a good success rate with freezing blastocysts and that is what the embryologist stated, so what do I believe and we are meeting again with this RE, what other questions should I pose to her.
And why did we not take the 10 embryos to blasts to begin with?
When the stimulation is managed properly, the estradiol level steadily increases throughout the stimulation phase of the cycle. It does not top out and then plateau.
Because embryo grading is, to a small degree subjective, there can be some variation between embryologists when grading the same embryo. However, I don't think that the stand-in embryologist was being too strict in the grading. I think the regular embryologist is too lenient. Often embryologists are pressured by RE's to overlook minor fragmentation and give the embryos an "A" grade, even when the embryo doesn't actually deserve it. This makes everything look better on paper and when the patient requests the records for a second opinion, the RE and lab will look good. A stand-in embryologist does not have a vested interest in making the program look good and therefore "calls 'em and he sees 'em".
Both the rate of division (cell number) and the degree of fragmentation (grade) are important in assessing the developmental potential of the embryo. Neither factor is more important than the other. Both the cell number and degree of fragmentation are taken together to form an opinion about the developmental potential of the embryo. I think ts important to point out that RE's are medical doctors that do not have extensive scientific training in clinical embryology. Any opinions from an RE about the developmental potential of embryos should be interpreted with caution. The defensive reaction from your RE underscores this point. If you are trying to come off as an expert and someone asks you questions you can't answer, well, you know what they say, the best defense is a good offense.
The strategy of thawing the frozen embryos and growing them to the blastocyst stage is a good one. However, its difficult to believe that the lab is still struggling with blastocyst freezing since the methodology for blastocysts freezing and thawing has been standardized for at least 5 years. There are actually FDA-approved, commercially available kits for freezing and thawing embryos at the blastocyst stage. The reason they do not freeze at the blastocyst stage may have more to do with economics than success (i.e. more patients will have embryos to freeze at the cell stage than at the blastocyst stage). More patients having embryos frozen means more money.
Dr. Smith My truest desire is one day to properly express my gratitude to your wonderful, informative and very educational replies. OUr struggles prior to this RE have been indescribable and bordering on criminal. Yes harsh words, but it borders on criminal. But we will not focus on that.
Our donors estradoil readings were whited out on her stimulation protocol sheet, from day 3----all the way till day 11. Interesting.
I understand your point about the embryologist and the grading of the embryos. I think you are exactly right, about the normal embryologist being there bc in a prior cycle our embryos were a b+, with the lenient embryologist.
Have you heard of doing assisted hatching on donor egg embryos. There was definitely a zona pellucida problem, it was clear on the picture of the embryos. You could see the thick outer shell. Would poor response to stims be a reason for thicker outer shell or is it something that you can not predict or know about in advance only when the embryos are made. Would the eggs look a certain way in culture that could indicate that the embryos would have a thicker outer shell from the embryos.
Would it be correct of me to ask what the success rates for assisted hatching is in this clinic and base it on the embryologist experience.
The 8 cyrofrozen embryos (2) are b grade(which could be b+ with the non standin embryologist), and 6 of the embryos are b- 6 and 8 cell embryos. They froze a 9 cell c embryos. Would you ever freeze a c cell embryo and perhaps it was bc the embryo was 9 cell.
Also it was noted at this clinic that an additional fees were collected if there were 10 or more embryos to freeze versus 9 and less, and that is the reason we feel they froze the c embryo.
There were 10 embryos that were viable, and what factors determine when embryos are taken to blastocysts? Cleve time in the 2 days, fragmentation rates, not sure exactly the factors to look for here.
Actually our clinic has a storage capacity, and after a year of storage is making couples send their embryos out to another facility, which of course reduces the costs involved in the laboratory. This clinic must have experienced an in crease in clients for this storage capacity. If there is a storage issue, from a business standpoint, would it be prudent to take all embryos to blastocysts.
What would be the reasons other than economics for not taking the embryos to blastocysts?
One theory is if they take the embryos to blastocysts and they do not make then the couples are more apt to blame the doctor if there is nothing to transfer.
I have learned some reading your board, and especially the 3 day versuses the 5 day. This RE said she does not like to do 5 day bc some of them will not make, and that was my point back to her, is why endure all those drugs if we do not have a chance.
I just want to thank you so much, I wish I could express my gratitude in a better way. You have been a much needed blessing in our struggles, I want to know that and I just so appreciate it and can not stop thank you
Although donor confidentiality must be maintained, "whiting out" of lab values in your copy of the donor's cycle stimulation sheet goes beyond maintaining confidentiality. It is suspicious.
One on the indications for assisted hatching is the presence of an abnormally thick zona pellucida (ZP). As far as I know, the thickness of the ZP is not related to the response (i.e. poor vs. good) to the stimulation medications. When I see embryos with abnormally thick ZP, it is usually patient specific and is consistent from one cycle to the next for that patient. In other words, there are some women that make thicker ZPs than others. Although assisted hatching is not routine in donor cycles, if an abnormlly thick ZP is observed, assisted hatching should be considered.
You should ask the embryologist what their indications are for performing AH.
When fragmentation is significant (i.e. Grade C), it becomes very difficult to determine what's a large fragment and what's a true cell at the advanced cell stage (i.e. 8+ cells). In this case, the Grade C is probably more telling than the number of cells. Grade C embryos usually exhibit poor survival upon thawing (i.e. only a few cells survive). As you observed, there could have been an economic incentive to freeze the one additional embryo.
One of the driving forces behind culturing "extra" embryos to blastocyst stage prior to freezing was the storage space issue. When freezing at cell stage, an amazing number of embryos accumulate in the storage tanks. The legal liability for the clinic increases proportionally with the number of embryos stored. Hence, the decision to out-source embryo storage to long term facilities. So, if you don't have to worry about storing the embryos, then there would be an economic incentive to freeze as many embryos as you could (and, of course, charge for it) and then out-source the embryo storage, so that it becomes someone else's problem. Oh, did I mention that long term storage facilities charge an arm and a leg for transportation and storage of the embryos (of undetermined developmental potential). Sound like the game's rigged? You bet.
The other, more immediate, economic drive to avoid blastocyst culture is so that all patients will have a transfer (around 5% of patients do not have embryos that develop to the blastocyst stage and therefore, do not have a transfer). If everybody gets a transfer, then you can charge everybody for a transfer. Dollars and sense.
Extended culture to Day 5 does NOT pose any additional danger to the embryo. There is no justification of Day 3 transfer from that point of view. If an embryo has the correct genetic instructions for continued development it will develop in vitro or in the uterus. If an embryo does not have the correct genetic instructions for continued development, it will stop growing wherever it is (lab, tubes, uterus, Mars).
Fear of facing the patient with the "nothing for transfer" news is the main reason RE's stick with Day 3. They justify their position with published studies showing that pregnancy rates do not increase when performing blastocyst transfers. This is probably true, since fewer blastocyst stage embryos are transfered to achieve the same pregnancy rate as Day 3 transfer. Pregnancy rates are an "all or none" and do not take into consideration multiple gestation (twins, triplets, etc). Twins, triplets, etc., put the babies and the mother at considerable risk and result in higher incidences of congenital abnormalities, learning diabilities, etc. Pregnancy rates are not the mesurement to use when comparing Day 3 with Day 5 embryo transfers. The implantation rate of the embryos (babies per embryo transferred) would provide a more meaningful comparison. The implantation rate of blastocyst stage embryos 2-3X higher than Day 3 embryos. Pregnancy rates aside, there are a variety of other positive reasons to culture the embryos to the blastocyst stage, i.e. more information about the embryo's developmental potential, additional diagnostic information to explain previously failed cycles, reduction in high order multiple gestation, etc.
Unfortunately, until doctors in the U.S. are forced to reduce the number of embryos transferred (as has been legislated in many European countries), they will continue to transfer large numbers of embryos on Day 3.
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6&8 cell embryos and take them to blastocysts, and I told her why then did we not take them to blastocysts to begin with. It was our understanding our clinic does not have a good success rate with freezing blastocysts and that is what the embryologist stated, so what do I believe and we are meeting again with this RE, what other questions should I pose to her.
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