quality of embryos
6 Replies
wantababy - November 23

Dr. Smith,
I recently experienced IVF for the first time. They retrieved 9 eggs and 6 fertilized. They transferred 2 Grade 2, 8-cell embryos 3 days after retrieval(with assisted hatching). 11 days after retrieval I was told I was pregnant. However my level of HCG was 39. They told me they were cautiously optimistic. Unfortunately, 2 days later my levels dropped. They did freeze two embryos (one grade 3 and one grade 4) and one blastocyst(uncertain of grading). My question is if they recommend I use the frozen embryos for my 2nd attempt should I agree? My concern is that the two they froze are a grade 3 and 4. I didn't have success with transferring two grade 2. If they transfer the grade 3 and the blastocyst, don't they have to trasfer the grade 3 on day 3 and the blastocyst on day 5? They probably won't do that. Thank you for your reply.


Dr Smith - November 25

Different labs use different grading systems. Some use Grade 1 as the best, some use Grade 4 as the best. Unless I know which system your program uses, I can't tell you much about the quality or developmental potential of the frozen Day 3 embryos. Assuming that Grade 1 is the best, I wouldn't hold out much hope for the Grade 3 and 4 Day 3 embryos.

If they were to thaw and transfer all the frozen embryos on an upcoming cycle, they would thaw the Day 3 embryos first, culture them for 2 days in an attempt to get them to develop to the blastocyst stage, and then thaw the blastocyst immediately prior to transfer. In that way the embryo development will be synchonized with the uterine lining and they won't have to transfer embryos twice (which could be detrimental).


nzteach - November 25

Hi Dr. Smith...I am posting this for wantababy as she was unable to post a reply...

Dr. Smith,
Thank you for your reply. Why would they freeze grade 3 and grade 4 embryos if chances aren't good? They told me that they would not freeze anything that was not worth freezing indicating that grade 3 and 4's have as good a chance to lead to pregnancy as grade 1 and 2's. We'll see what they recommend. My concern is that they'll recommend I transfer the grade 3 and grade 4 on day 3 rather than seeing if they can make it to blast stage to use with my other already frozen blast. I have another question for you. I am 34 years old. Infertility diagnosed as moderate endometriosis of ovary. I already had one laparoscopy/hysteroscopy and they removed one cyst(endometrioma) on my left ovary and the endometriosis. Before IVF they spotted another endometrioma(cyst) on my left ovary, but claimed it
wouldn't interfere. My left ovary actually produced more follicles than my right. My question is do you think that the endometriosis had anything to do with the loss? Do you have any recommendations for what to ask for from the RE as to the transfer and my two grade 3 and 4 embryos? (keeping in mind I do have one frozen blast, which I will be asking them the grading of that as well)

Thank you.


Dr Smith - November 25

As I said, I don't know their grading system, so that's the first question you need to ask. In the traditional grading system, if Grade 1 is the best, then Grade 3 and 4 wouldn't be worth freezing. So that's another question to ask - why freeze poor quality embryos. If they suggest thawing the two embryos from Day 3 and leaving the blastocyst stage embryo for a "later" cycle, ask them to do as I suggested. IVF is an elective procedure. You are in control of your embryos, not the doctor. If they are oncerned that the Grade 3 and 4 embryos are not capable of reaching the blastocyst stage, why are they transferring them? Putting them in your uterus won't magically make them better. If they have good developmental potential, they will develop to the blastocyst stage in the lab. If they don't, they wouldn't have anyway and then you know you need to thaw the blastocyst for transfer - on that cycle.

Endometriomas can cause damage to the eggs in adjacent follicles. The damage may be permanent, so even when they remove the endometrioma, it won't necessarily improve the quality of the eggs that were adjacent to the cyst(s). If eggs from follicles adjacent to the endomretioma are retreved, they often have a dark appearance and undergo excessive fragmentation when fertilized. They rarely develop beyond the 4-cell stage. Since at least two embryos reached the blastocyst stage, there are still some good eggs in your ovaries. Endometriomas are encapsulated and are not thought to be as detrimental to implantation as open endometriotic lesions in the pelvic cavity. So no, I don't think the remaining endometrioma caused the early loss. However, if endometriotic lesions are present in the pelvic cavity, they can trigger an inappropriate immune response and that can result in an early loss. You may wish to consider being tested for natural killer cell level activation.


nzteach - November 25

Hi Again...this is from wantababy again...still having bulletin board problems.....

First of all, thank you so much. The clinic I use does grade with 1 being the best. As of now, they have continued to tell me that grade 3 and 4 levels can be successful. I believe they are at least between 6-8 cells. I will ask about the darkness, although the pictures I have of the 2 grade 2 ones they transferred do not look dark, but I don't know about the remaining ones. I agree and am concerned as well about simply transferring them without letting them develop to blast stage before transfer. I have a feeling though that that is what they will insist being that they keep saying they wouldn't freeze them if they weren't viable when I ask about them being such low grades.

My next question is about the lesions, could you explain about that a little more. When they went in to "clean out the endometriosis" was that getting rid of lesions or would that possibly cause more? And is there a treatment or way to get rid of the lesions if I do have a high natural killer cell level? I know it has been a year since I had my last procedure for the endometriosis, should I expect to probably have to have another surgery prior to my next IVF?

Thank you again.


nzeach - November 30

not sure if you saw this, do you have any info on the endometriosis lesions or a place to look and read more for us?

thanks so much!


Dr Smith - November 30

Thanks, You were right. I read your post, but forgot to reply.

From what you posted it appears that your doctor also "burned" any endomtriatic lesions in your pelvis when removing the endometrioma. However, the burning is only good for about 6 months as new lesions appear thereafter. The laparoscopy does not cause more endometriosis, but it can cause scarring (adhesions) in the pelvis that could interfer with natural fertility. Since you're doing IVF, it won't matter if adhesions form. I'm not a physican, but I think its a good idea to have another lap to "burn" any new lesions before trying IVF again.

You should also consider being tested for natural killer (NK) cell level and NK activation (abnormal NK activation is also important). The NK cell level, once elevated, will not return to normal following the removal of the latest endometriotic lesions. Neither will abnormal NK activation. Intravenous immunoglobulins (IVIg) are used to treat elevated NK cells or abnormal NK activation. You receive this treatment prior to embryo transfer and , if you become pregnant, monthly through the first trimester. IVIg treatment is controversial (although it works very well in our hands), so discuss this with your doctor.



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