You’ve been so INVOLVED up to this point. Administering shots and going to your checkups made you feel “in control” (even if that is an illusion). But then you arrive at the clinic for retrieval, and it’s all out of your hands. 

It’s even out of your physician’s hands. Your eggs are about to pass through a tiny window, into the hands of an embryologist you have never met. 

You are usually asked to arrive at your clinic two hours ahead of your retrieval. You will be asked to fast for at least 12 hours. Once you get checked in and changed into a not-so-fancy robe, you’ll be asked to empty your bladder before being wheeled into the operating room.

What happens in prep for Egg Retrieval? 

The Embryologist will do a “time out” through the tiny window that leads to the sterile lab. They will confirm your name, date of birth and IVF cycle plan with the physician. Then you will start to go under, as the anesthesiologist puts you “to sleep”. 

After you are comfortably asleep, the nurses, medical assistants and physician will drape all of your exposed skin with soft sterile towels. The vagina is washed and prepped for the ultrasound guided transvaginal oocyte retrieval. The physician positions the gooseneck light, and the OR lights are turned down low for the retrieval to begin!

What happens during Egg Retrieval?

In short, the Embryologist goes hunting for eggs. They look for eggs in every shape and size and depend on eggs being surrounded by a nice “cloud” of fluffy, nurturing cumulus cells. 

In general, your last scan tells your physician and embryologists how many eggs to expect. They make that determination based on the number of follicles over 14 mm. They are also seeing if the “small” follicles did or did not hold a mature egg.

As the tubes of follicular fluid are handed through the window, they are taken into a dark, warm, and humid environment. They then pour the fluid into a petri dish and start examining it closely under a microscope. As an Embryologist finds eggs, they count to your clinical team; One, Two, Three, and so on. 

Mostly, the number of eggs expected are retrieved and sometimes, you get a huge surprise and get more eggs than expected! Occasionally, there are retrievals that yield no eggs. There are several reasons that can occur; something went wrong with the stimulation protocol. Maybe only one egg was expected, but it can’t be found. Perhaps the patient didn’t time the trigger correctly or the surgery started late and the patient ovulated, or the trigger didn’t “absorb” properly. Maybe it’s a rare case of empty follicle syndrome. Whatever the cause, “no egg” retrievals are devastating.

At the same time as your retrieval is happening, the sperm for your egg insemination is being processed. Maybe it is being thawed, or in the case of fresh samples, it is being separated from the semen of the ejaculate and being prepared so the best most “motile” sperm will be available for later use.

What happens in the lab post Egg Retrieval?

After the eggs are collected they are washed, and sometimes they rest in the cumulus cells in an incubator hoping for any last – or slow maturation to happen, before they are processed further. 

In conventional IVF the eggs stay in the cumulus until they are combined with sperm cells. But if ICSI will be performed, then they are “striped” of the cumulus cells, graded, and their quality assessed. 

On average, about 80% of the eggs that are retrieved will be mature enough to fertilize. To assess egg maturity and quality, an embryologist dissolves the cumulus cells from around the eggs with an enzyme. Then gently swish each egg cell up and down in a tiny pipette, about the width of a sharp pencil lead. In the end they only want to see one single, clean cell- THE EGG!

Then only the mature and healthy eggs are then separated for fertilization. Mature eggs are referred to as “MII” ie. “meiosis two” ready oocytes. Besides seeing nice mature MII oocytes, the lab may see slightly immature eggs, called MI (Meiosis I) or very immature eggs called “GV” (ie geminal vessicle). Unfortunately, sometimes we see eggs that have fractured zonas, or are severely compromised due to vacuoles, dented cyctoplasm, or other abnormalities. 

Whether you and your physician opt for ICSI or conventional IVF, or if your lab only offers ICSI, your eggs will be combined with your partner or donor sperm within a few hours of the egg retrieval. This is referred to as “insemination” and it is not the same as fertilization. 

To learn more about insemination and your choices of ICSI or IVF, click here.

The post What Happens During An IVF Egg Retrieval? appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

Why is my Egg Fertilization Rate Low? 

And more importantly, is there anything that can be done about it?

Understanding the exact cause of TFF is extremely difficult. Some of the most common causes are:

Poor Egg Quality:

Once injected, an egg needs to go through certain processes in order to become ‘activated’. ‘Oocyte activation’ renders the egg capable of becoming fertilised. Failure of oocyte activation is one of the most common reasons for failed fertilisation after ICSI, accounting for over 50% of TFF cases.

Egg Maturation Issues:

An egg can degenerate following ICSI if it is post-mature or if the egg matured immediately prior to injection. Eggs falling to achieve good maturation may be due to hormonal stimulation methods which did not suit you.

Sperm Issues:

Failed fertilisation due to sperm factors has been linked to sperm morphology, sperm nuclear morphology, acrosomal factor and sperm chromatin status. Issues with sperm head decondensation can lead to the sperm’s DNA remaining ‘locked’ inside the sperm head and not being released into the egg. This inevitably leads to failed or abnormal fertilisation.

Technical Issues:

A rare cause of TFF after ICSI can indicate poor technical skill of the embryologist – as it is possible for an egg to be damaged by the injection process.

How can my egg fertilization rate be improved?

The life cycle of an egg is long, complicated & prone to errors. By improving your lifestyle & nutrition and supplementing with the correct antioxidants, egg health may be improved. 

The human egg starts its final developmental cycle about 90 days before ovulation, so it’s important for these adjustments to take place during as much of these 90 days as possible.

A change in treatment protocol and/or stimulation medication may also improve your results.

In cases with persistent failed fertilization (after different meds and protocols were used), using assisted oocyte activation (AOA) is currently the only available method to improve fertilization rates. 

Activation can be induced with the use of electrical, mechanical, or chemical stimuli that elevate intracellular concentrations of calcium ions (driving force behind activation). However, these methods work by flooding an egg’s ooplasm (the inside of the egg) with calcium ions that don’t follow the physiological cascade. 

This practice raises concerns, as these chemicals may affect embryo viability and future offspring due to their potential cytotoxic, mutagenic and teratogenic effects.

The post Why Is My Egg Fertilization Rate Low? appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

Here are some of the most common reasons your IVF Cycle Failed…

Implantation Failure

When good quality embryos do not implant there may be issues with:

• Uterine anatomical abnormalities can include Fibroids, polyps and septums which may interfere with the embryo’s ability to implant and grow. 
• Lack of luteal support is when your progesterone levels are too low or additional estrogen support is required.
• Immune issues or an increase in NK cells could mean that your body is attacking your embryo. Immune testing is not a routine fertility test and not conducted by all fertility clinics. Make sure to speak to your doctor about this or see a reproductive immunologist for additional testing to rule out immune issues. 
• Thrombophilia and blood clotting issues include conditions in which there’s an imbalance in naturally occurring blood-clotting proteins, or clotting factors that could keep blood from flowing properly to your uterus or create clots that interfere with implantation.
• Receptivity issues / endometrial thickness may not be achieved if your lining is under 8mm at the time of your trigger shot. This may mean that you need additional estrogen and progesterone support. Your receptivity can be measured using an ERA test during a mock transfer. 
• Genetic issues (aneuploid embryo) for non tested embryos.
• Zona pellucida issues: embryo hatching abnormalities
• Poor choice of transfer day if your clinic doesn’t operate every day.

Arrested Embryonic Development

When embryos stop growing in the embryology lab before embryo transfer the causes may be because of…

• Egg Quality issues are usually suspected if an embryo arrests during the cleavage stage of embryonic development (days 1-3) as the maternal genome is in charge of cell divisions during this time. Failure of embryonic genome activation is suspected if the embryo does not progress beyond 8 cells. On day 3 of embryonic development, the embryo has to switch its genome on and take over cell divisions – if this doesn’t happen the embryo cannot continue to develop.
• Poor Sperm Quality or sperm DNA fragmentation
• Genetic Reasons (aneuploidy)
• Poor embryology lab quality is usually down to poor culture environment/embryo handling. Ask your clinic for their Key Performance Indicators (KPIs). What is their overall fertilisation rate for your age group? What are their cleavage and blastocyst formation rates? Compare these to international benchmarks.

Ask your embryologist for your personal statistics and compare these to the benchmarks for your age group. In some cases small adjustments to a future cycle can make a difference between an IVF cycle fail and success.

Sometimes, however, the only option is to gather the strength to try again and remember that IVF is a treatment with cumulative chances of success.

The post Why Did My IVF Cycle Fail? appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

The sobering truth is that while IVF has been around for over 40 years, protocols are still administered on a trial and error basis. While most women will respond well to the Antagonist/Short protocol, others may require multiple IVF rounds to find the right protocol and medication cocktail for them.

This is where Embie’s mission becomes so important. By collecting diagnosis and IVF protocol information from thousands of women around the world, we hope to find markers for treatment best practices moving forward. This will mean more precise protocols for your specific diagnosis, higher success rates and lower costs for future infertility patients. 

As medicine advances, the 5 below stimulation protocols can be combined with autoimmune protocols, priming protocols (estrogen or testosterone), the addition of HGH (Human Growth Hormone), steroids, and other treatment options subscribed by your RE based on your diagnosis. 

Antagonist IVF Protocol:

The most standard and used protocol in IVF is the Antagonist a.k.a. Short protocol. It has a high success rate amongst younger patients, those with higher ovarian reserve (AMH/AFC), PCOS diagnosed patients, and those of African American and Asian ethnical backgrounds.

Antagonist Protocol Treatment usually follows the below protocol:

1. Begin with two weeks of Birth Control Pills to suppress the ovaries.
2. Stop BCP, wait for Menstrual cycle and begin Stimulation drugs such as Follicle-stimulating hormone (FSH) and/or Human menopausal gonadotropin (hMG, combines LH and FSH) on CD2 or CD3. 
3. Starting around the fifth day of stimulation, the Gonadotropin-Releasing Hormone (GnRH) antagonist is added to prevent premature ovulation.
4. Once your follicles have been determined to be ready, Your doctor may use a “Lupron trigger” or “dual trigger” with HCG to promote the final maturation and release of the oocytes 34-38 hours prior to egg retrieval.

Long Agonist IVF Protocol:

The Long Agonist a.k.a. Lupron Protocol may be used in older patients or in patients who have poor egg and embryo quality from other protocols. It has also been found to improve the clinical pregnancy rate of patients with stages III–IV endometriosis and those with lower ovarian reserve (Low AMH/AFC).

Long Agonist Treatment usually follows the below protocol:

1. Begin with two weeks of Lupron/Decapeptyl, a.k.a Gonadotropin-releasing hormone agonist (GnRH agonist), to suppress the ovaries. Some patients may be given BCP prior to the administration of the GnRH agonist medications. 
2. Once the ovaries have been determined to be sufficiently suppressed via ultrasound and lab results (Low Estrogen, LH and FSH levels), stimulation drugs will be administered. Follicle-stimulating hormone (FSH) and/or Human menopausal gonadotropin (hMG, combines LH and FSH) will be taken for 10 to 20 days depending on the patient’s response. 
3. GnRH Agonist (Lupron/Decapeptyl) will continue to be taken at a lower dose throughout the stimulation portion of the protocol to prevent premature ovulation. 
4. Once your follicles have been determined to be ready, Your doctor will instruct you to administer a HCG trigger to promote the final maturation and release of the oocytes 34-38 hours prior to egg retrieval.

Flare IVF Protocol:

Called the Flare, the Microdose Flare, or the Low dose Lupron protocol, this regimen uses the same medications as the Long Agnois protocol. The major difference is that, by cutting the dose of Lupron down to one sixth of the routine dose, and by giving it twice daily, the Lupron actually turns the pituitary gland “on” rather than “off”, producing a major release of FSH.  

Much like the Long Protocol, it is subscribed to poor responders and women of older maternal age or low ovarian reserve (AMH/AFC).

Flare Protocol Treatment usually follows the below protocol:

1. You’ll begin down regulation using a microdose of Lupron/Decapeptyl, a.k.a Gonadotropin-releasing hormone agonist (GnRH agonist), twice a day for a very short period of 3 to 5 days starting on CD1-CD3.
2. Once instructed by your Clinic, begin stimulation drugs such as Follicle-stimulating hormone (FSH) and/or Human menopausal gonadotropin (hMG, combines LH and FSH) for approximately 10 days, while continuing to take the GnRH agonist. 
3. Once your follicles have been determined to be ready, Your doctor will instruct you to administer a HCG trigger to promote the final maturation and release of the oocytes 34-38 hours prior to egg retrieval.

Mini IVF Protocol: 

In some rare cases, there are clinics that believe that “minimal” stimulation may provide advantages and improve egg quality in low responders and those with diminished ovarian function. A mini or natural IVF cycle will yield only one or two eggs at a time in hopes of getting quality over quantity.

Mini IVF Protocol Treatment usually follows the below protocol:

1. Your doctor may advise using fertility pills, such as Clomid and Femara/Letrozole, or very low dosage FSH and hMG medications for a shorter period of time, later in your cycle. This will be determined by monitoring your cycle via ultrasound and lab tests. 
2. Gonadotropin-Releasing Hormone (GnRH) antagonists may be added to prevent premature ovulation.
3. Once your follicles have been determined to be ready, Your doctor may use a “Lupron trigger” or “dual trigger” with HCG to promote the final maturation and release of the oocytes 34-38 hours prior to egg retrieval.

Ultimately, ovarian stimulation is a very complex process. With so many different stimulation regimens developed and studied, it’s important for you to discuss your options in detail with your physician and choose the absolute best protocol for your individual circumstances. 

The post What Kind of IVF Protocols Are Available? appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

The results will help your RE determine the stimulation protocol that’s best for your situation. This is a critical piece to your IVF success as too little or too much medication can significantly impact your egg quality. 

Your clinic will provide you with a list of medication, dosages and calendar for your key dates and monitoring appointments for your IVF stimulation cycle. Make sure to enter this info in the Embie app to keep track and set reminders of your daily protocol activities. 

Taking your medications on time is crucial during IVF. If you’re a few hours off, you can experience premature ovulation or miss your egg retrieval window. 

In most cases, an IVF stimulation cycle begins with a baseline monitoring appointment. This is done on day 2 or 3 of your period or on day 21 (post ovulation), depending on your protocol. 

If everything checks out during your baseline appointment, you are given the green light to begin your cycle. 

Ovarian Suppression/Down Regulation:

The process starts with ovarian suppression through the use of birth control pills and/or Lupron/Decapeptyl, which usually lasts around 12 to 14 days. This is done to allow your clinic more control and the even growth of your follicles (pockets of fluid which typically contains eggs). 

Ovarian Stimulation & Monitoring:

Once ovarian suppression is achieved you then start ovarian stimulation with recombinant follicle-stimulating hormone (FSH) and/or Human menopausal gonadotropin (hMG, combines LH and FSH) medication. The stimulation is monitored through ultrasounds performed every 3 to 4 days along with blood hormone measurements including estradiol and progesterone.

Gonadotropin-releasing hormone antagonist (GnRH antagonist) drugs such as Cetrotide may be introduced 5 to 7 days into your stimulation phase to prevent you from ovulating prematurely. 

Once the majority of the follicles are in the 16 to 20mm size, ovulation is triggered with human chorionic gonadotropin (hCG) or Gonadotropin-releasing hormone agonist (GnRH agonist) depending on your protocol. The trigger shot starts the ovulatory process which is required for egg maturation. 

Egg Retrieval:

The egg retrieval procedure is then typically performed under anesthesia, 34 to 38 hours after the trigger is administered.

While you’re asleep, an ultrasound wand is put in the vagina. A needle is guided along the ultrasound into each follicle on the ovary and an egg is removed with a low grade suction.

The fluid is handed to the embryologist who then searches through the fluid to identify the mature eggs and prepare them for freezing or fertilization.

The post What happens during an IVF Stimulation Cycle appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

After your egg retrieval, your clinic will determine if a fresh embryo transfer is recommended based on several factors; the amount of embryos fertilized, estrogen and progesterone levels, and the health of your uterus (thickness and shape of your uterine lining, is fluid present, etc).

Fresh transfers can occur on day 2, 3 or day 5 (Blastocysts) depending on the development of your embryos. *Link to embryo related article here*

Prepping For Your Fresh  Embryo Transfer:

One day post egg retrieval you’ll begin a fresh transfer prep protocol that usually includes estrogen and progesterone supplementation. These medications can be taken orally, via a patch, suppositories or injections. 

Fresh embryo transfers often require a higher amount of progesterone medication due to the fact that the corpus litmus isn’t able to secrete progesterone since the egg retrieval eliminates it. 

If you have autoimmune factors, your protocol may include blood thinners and/or steroids.

The Day of Your Fresh Embryo Transfer:

You’ll be asked to arrive at your clinic with a full bladder (drinking up to 1 liter of water). You’ll get checked in, change into your medical gown, and asked to identify yourself and the Embryo. 

Your Embryo(s) are placed in a catheter, and inserted through your cervix into your uterus under ultrasound guidance. The procedure itself is usually painless and doesn’t take more than a few minutes. 

Post Fresh Embryo Transfer:

You’ll continue to take your medication protocol and be given an official pregnancy test date. Some clinics will require a BETA Hcg blood test and others (mostly in the UK) will ask you to confirm the cycle’s outcome via a home pregnancy test. 

In the Embie app you’re able to create an embryo report, schedule your transfer, track your medication protocol, and enter the results of your cycle all in one convenient place. 

The post What happens during an IVF Fresh Embryo Transfer Cycle appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

Perks of waiting for an FET vs doing a fresh transfer include allowing your body to heal after the egg retrieval, doing genetic testing (PGS/PGT) on the embryos and fully controlling the development of the uterine environment (unless you opt for a natural transfer cycle).

Some of the cons of going with an FET are longer wait times and the additional costs of medications and monitoring.

The decision to go with an FET should be made jointly by your RE, the embryologist and yourself. Once you’ve agreed on a FET the next question is if you’ll have a natural or controlled protocol?

Natural Frozen Embryo Transfer Cycle:

A natural FET cycle allows your transfer to follow your body’s lead. You will wait for your menstrual cycle to begin, and have a baseline monitoring appointment 7-10 days later. 

The monitoring appointment will include an ultrasound to check the progress of your uterine lining and follicles, as well as to make sure there aren’t any cysts in the way. Labs will be drawn to check adequate estrogen and progesterone levels.

Once your lining and follicles are determined to be ‘matured’, you will be instructed to trigger ovulation and begin the medicated portion of your transfer protocol. 

Controlled Frozen Embryo Transfer Cycle:

A controlled FET often begins with a baseline monitoring appointment around the time you ovulate (between day 13-15 of your cycle). 

If no cysts are present, the medicated part of the protocol starts by suppressing the woman’s pituitary gland to reduce the chances of unexpected ovulation. This is done with approximately two weeks of Gonadotropin-releasing hormone agonist (GnRH agonist) injections.

A second monitoring appointment is scheduled to assess the full suppression of your ovaries, and if satisfactory you’ll begin to prime your uterine lining using estrogen hormonal supplements. Estrogen acts to thicken and mature the uterine lining – like the natural estrogen produced by a developing egg follicle during a normal menstrual cycle.

You will continue to be monitored until your uterine lining reaches at least 8mm, at which point you are ready to transfer prep.

Preparing for your Embryo Transfer:

Once you ovulate via trigger and/or are cleared for transfer during a controlled cycle, you’ll add progesterone to your protocol. Progesterone is a medication administered to make the uterine lining receptive to the implantation of the embryo. 

Typically, progesterone is administered in a combination of oral, suppository and/or injections. The regimen of progesterone administration completes the final stage of the Frozen Embryo Transfer (FET) preparation process and sets the actual embryo transfer procedure in motion for 5 days later (when transferring a blastocyst). 

The Day of Your Embryo Transfer:

You’ll be asked to arrive at your clinic with a full bladder (drinking up to 1 liter of water). You’ll get checked in, change into your medical gown, and asked to identify yourself and the now thawed Embryo. 

Your Embryo(s) are placed in a catheter, and inserted through your cervix into your uterus under ultrasound guidance. The procedure itself is usually painless and doesn’t take more than a few minutes. 

Post Embryo Transfer:

You’ll continue to take your medication protocol and be given an official pregnancy test date. Most clinics will require a BETA Hcg blood test and others (mostly in the UK) will ask you to confirm the cycle’s outcome via a home pregnancy test. 

In the Embie app you’re able to create your transfer protocols by scheduling your transfer, tracking your medication protocol, and entering your appointments and  the results of your cycle all in one convenient place. 

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