question about lab
4 Replies
Lila - August 22

If I may bother you with yet one more question - you have mentioned that it is a good idea to check out the labs at our clinic, especially if you are thinking about asking about the 5 day transfer possibility. I was wondering how you would advise going about that - checking out the lab?

I do not think (but could be wrong) any of the CDC reports provide that info and I have not had any contact with the lab at my clinic to ask them direct questions. To be honest I am afraid even if I did I would feel very badly asking them things like their blast success rate, do you have the tri gas incubator, etc - is it impolite to directly question a lab/Embryologist like that? I really do not want to offend someone who is going to be so critical to my success. Are there any other places a lay person could research this kind of info?

Sorry for the obsession about the 5 day I had just not realized the importance till I found and read your posts. Also I think I am channeling my stress into doing too many research projects (something my clinic warned about), but at least it gives me some sense of control. Thank you for any advice it is much appreciated.


Dr Smith - August 23

You are correct. The CDC data does not specify what was transferred or when the transfer occured (they are collecting this information, but do not publish it in the annual reports). They do, however, report how many embryos were transferred. You can read between the lines. If the average number of embryos transferred is close to 2, then they are culturing at least some embryos to the blastocyst stage. If the number is closer to 3 or above, they are transferring strictly on Day 3.

There's nothing wrong with questioning your RE about the experience in the lab for any given procedure whether it be ICSI, AH or blastocyst culture. Remember, infertility treatment is elective. No one is dying here. You are entitled to that information and should not feel that asking questions will jepordize your care. If you get a defensive response from the RE, you can assume they have little experience. Time to move on. Think of yourself as a consumer of medical services. If you heard that the cardiac department of a particular hospital had a high mortality rate, you would have open heart surgery there, would you?

The clinical efficacy of blastocyst culture is in debate. You will find studies that show blastocyst culture results in higher pregnancy rates, while others will claim that it doesn't matter. The problem is that pregnancy is an "all-or-none" endpoint and does reflect the advantages of blastocyst culture. Its easy to improve pregnancy rates simply by transferring a gazillion embryos. Of course that results in high order multiple gestations that put the babies and mother at risk. Furthermore, the studies claiming that blastocyst transfer does not improve pregnancy rates can be criticized in terms of their laboratory methods. Clearly, if you don't know how to culture embryos to the blastocyst stage, then its better to transfer the embryos on Day 3. What is irrefutable is that (when grown properly) the implantation rate for blastocysts is about twice that of Day 3 embryos, equivalent pregnancy rates can be obtained from transferring fewer embryos (triplets+ can be elliminated), and additional information regarding the developmental capacity of the embryos can be obtained, thus assisting patients decide wen its time to move on.

You have to really dig through the scientific literature to find the benefits of blatocyst culture. If blastocyst culture reduces high risk pregnancies (and doctors have known about blastocyst technology for 15+ years), then all the people that lost pregnancies due to triplets+ could sue for malpractice, couldn't they. Oooo, we wouldn't want that, would we? It continues to be politically correct to pooh-pooh blastocyst culture - except in some countries in Europe where single embryo transfer is required by law.


Lila - August 23

Thank you again for not just provding an aswer but also an education. I really appreciate that you take such time and effort to help. I can not tell you how much it means.

I understand what you are saying about the debate within the field RE blastocysts. For me I keep thinking of them as "better" in terms of learning information. I do not want to do a cycle just to do it and then sit around with fingers crossed for two weeks. Ideally as this is my first IVF I would like to learn as much as possible about where my problem(s) might lie. As I am one of the 20% "unexplained" I hope to see from this IVF if
1. I can produce eggs
2. hopefully they are of acceptable quality - not dark and grainy etc
3. Egg can meet Sperm and everyone can do their job
4. Day 1-3 can show developmental skills of egg
5 Day 3-5 can show developmental capabilities of sperm as well as continues ability of the embryo to develop to something with potential to implant.

I think my fear with this cycle is not the ultimate failure but getting the negative without knowing anything else that I know right now. I understand that is still possibe no matter what happens but again ideally I would like a senario with the most potential to provide feedback information if in fact we do fail at this cycle. Not trying to be negative just pragmatic.

On the same issue but from a different angle I also think given our current political climate that the IVF industry would be smart to think more about transfering blasts as a way to start providing some limits from within the business before some of these yahoo Senators (Santorum and Brownbeck) start trying to put their ideas of limits into law. The direction they want to take to control embryos in my opinion would effectively gut the ability of fertility clinics to help so many people. Thus I think this may be one of those great cases where "Dr heal thyself " is so true, this should be handled by Doctors not Senators. If the REs and Embryologists could find ways like blasts to limit the number of embryos transfered and frozen then MAYBE the politicians on Capitol Hill will not be able to get enough traction to interfere in what really is none of their business.
Sorry just my opinion, and I apologize for standing on the soapbox. Thanks again for the answers.


Dr Smith - August 24

Right On! Of course, by using that expression, I just gave away my boomer age. Oh well, expressions may change (just listen to my teenage sons), but the sentiment remains.

Unfortunately, the pressure to maintain high pregnancy rates for marketing purposes remains strong. Patients reviewing the CDC data should also look at the percentage of multiple births, not just the pregnancy rates. Read between the lines folks. Many patients actually request twins without understanding the serious complications associated with multiples gestation. There are lots of articles in the internet that address this problem.

Compared to other countries, multiple pregnancies is out of control in US. IVF programs in the US have been severely critized by the ROW (rest of the world).


Dr Smith - August 24

In the "I couldn't have said it better myself" department:

This is an excert from the 1st Global Conference
Treatment of Infertility – Toward Avoiding High Order Multiple Gestation held in Bethesda MD in 1999 (Yes, 1999!!)

Dr. D. Dizon-Townson (USA)
Blastocyst transfer technology

Trounson AO, Batiza VA, Centre for Early Human Development, Monash Institute of Reproduction and Development, Monash University, Victoria, AUSTRALIA

Rates of multiple pregnancies (MP) associated with assisted reproductive technology (ART) have been quoted as high as 36%. The increased rates for multiple gestation associated with ART results in an increased incidence of both neonatal and maternal morbidity and mortality. The pressure to succeed with In-Vitro Fertilization (IVF) therapy, given the commonly poor insurance coverage and high costs, is so great that the temptation remains to replace a higher number of embryos to increase implantation rates. The complications of any MP are of consideration and include
medical, social, psychological, ethical and financial implications. IVF can become reasonably cost-effective by taking steps to eliminate high-order MP. The increased implantation rates (IR) for blastocysts transferred in human should result, not only in increased pregnancy rates (PR) but also in a decrease in multiple gestations by reducing the number of embryos required for transfer to achieve an acceptable PR. Embryo transfer in humans had been traditionally performed two days after insemination with PR between 10 and 34%. The reason could be the premature placement of embryos into the uterus. The analysis of pregnancy data showed no increase for pregnancy rate when three rather than two embryos were transferred, but MP was significantly increased.


• Patients with repeated implantation failure.
• Patients suspected of defects in oocyte quality, requiring embryos to be assessed for an extended period.
• Patients needing embryo biopsy for genetic selection.
• Patients undergoing replacement of supernumerary embryos frozen at the blastocyst stage.
• Select the most developmentally competent embryos for transfer.
• Synchronization of the embryo with the female tract, leading to increased IR.
• Selection by culture has an additional benefit for cryostorage of embryos, since only the most competent will be saved, resulting in fewer vials stored and fewer
problems with disposal of unwanted, long-term stored embryos.
• Sequential, physiologically based culture media can be used to produce highly viable human blastocysts.



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