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Frequently Asked Questions
Should I have a Day 3 embryo transfer or a Day 5 (blastocyst) embryo transfer?Should I have my IVF center perform Assisted Hatching on my embryos before transfer?
How many embryos should I have transferred back?
Patient selection criteria
Why should my doctor be a SART member?
What is validation?
Should I have a Day 3 embryo transfer or a Day 5 (blastocyst) embryo transfer?
Recent advances in the laboratory has led to the development of new culture systems capable of growing embryos beyond the Day 3 stage and to the Day 5 or blastocyst stage. This is achieved by using not one, but a sequence of culture media, each designed to meet requirements specific to each preimplantation stage. The availability of a number of successful sequential culture systems has led many programs of assisted reproductive technology to pursue blastocyst production and replacement.
The principal indication for Day 5 or blastocyst transfer is the reduction of ART-associated multiple pregnancy.
Approximately 40% to 60% of fertilized oocytes reach the blastocyst stage using contemporary sequential culture systems, but there are remarkable variations a patient’s ability to produce blastocysts. A risk of attempting blastocyst transfer is the possibility that no embryos will be available for replacement.
It is best to check with your individual clinic to assess the availability of and the clinic’s experience with blastocyst transfer.
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Should I have my IVF center perform Assisted Hatching on my embryos before transfer?
In vivo hatching of the blastocyst is a critical component of the physiologic events culminating in implantation. Conversely, the failure to hatch may be one of the many factors limiting human reproductive efficiency. The clinical application of assisted hatching has been proposed as one approach toward the enhancement of implantation and pregnancy rates following in vitro fertilization.
The assisted hatching procedure entails the creation of a gap in the outer area of the embryo called the zona. This is done either by drilling with an acid medium, by laser, or by using a piezomicromanipulator.
Success rates following the use of assisted hatching in different ART programs have varied considerably. Well-designed studies suggest that assisted hatching might best be used in patients > 38 years old or with multiple prior failed IVF cycles.
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How many embryos should I have transferred back?
The objective of infertility treatment should be the birth of a single, healthy child. Many of the treatment options presented to infertile couples, however, are associated with high risks of multiple gestation. Moreover, many couples view multiple gestation as desirable and are unaware of the risks they pose to both mother and babies. Couples should understand these potential risks before starting treatment.
The ability to limit the number of embryos or eggs transferred is an effective approach to limit multiple pregnancies. The Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) have published guidelines recommending an optimal number of embryos for transfer based on patient age, embryo quality, and other criteria.
See http://www.asrm.org/Media/Practice/NoEmbryosTransferred.pdf
In the United States, the decision regarding the number of embryos to transfer is made jointly by the physician and the patients. This decision should be based upon the best interests of the patient and the future offspring. However, ART is centrally regulated in England, and no more than three embryos may be transferred in most circumstances. In Canada, a recent Royal Commission recommended the transfer of a maximum of three embryos.
The ultimate goal is to achieve a high pregnancy rate while transferring a single embryo. Recent laboratory improvements have allowed programs to transfer two embryos while maintaining acceptable pregnancy rates. Eventually, the transfer of one embryo will resolve the issues surrounding multiple pregnancies.
Some clinics see more than the average number of patients with difficult infertility problems. Some clinics are willing to offer ART to most potential users, even those who have a low probability of success. Others discourage such patients or encourage them to use donor eggs, a practice that results in higher success rates among older women. Clinics that accept a higher percentage of women who previously have had multiple unsuccessful ART cycles will generally have lower success rates than clinics that do not. In contrast, clinics that offer ART procedures to patients who might have become pregnant with less technologically advanced treatment will have higher success rates than clinics that do not.
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Patient selection criteria
ART clinics attempt to individualize each couple's treatment plan to the couple's particular problem, preferences, and resources. Because of some uncertainties about the 'best' approaches in many cases, the range of treatment philosophies among clinics, and the vagaries of insurance coverage, it not surprising that what seem to be similar situations may be treated differently in various clinics. In order to help decide on the most appropriate treatments, clinics perform certain tests, and establish certain criteria for the test results, by which treatment decisions are guided. For instance, many clinics have established limits which, if exceeded, will preclude certain therapies because the expected success rate in those circumstances is so low. Currently, common examples of these limits include women over age 43, or those with elevated FSH levels, who may not be permitted to undergo routine IVF in some clinics, but are permitted IVF in others so long as the couple is informed of the low chance for pregnancy. Other clinics recommend stopping IVF if a certain number of prior IVF attempts have failed. All of these policies are designed to provide the best match of available treatments to the particular patient situation.
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Why should my doc be a SART member?
The Society for Assisted Reproductive Technology (SART) is the professional society for doctors and laboratory scientists who work together as a team to provide in vitro fertilization services. It is an affiliated society to the American Society for Reproductive Medicine (ASRM). SART is the place for these professionals to share information and experience. Many SART members meet on a regular basis at the annual ASRM meeting.
SART is setting the standards for the practice of IVF and provides its members with many guidelines for the continuing improvement of the practice of IVF. Guidelines for ovarian stimulation, numbers of embryos to transfer and the appropriate use of donor gametes are examples of a few of such guidelines. In addition, guidelines regarding ethical considerations, laboratory practice and proper advertising are also published. SART members are obligated to abide by these guidelines.
SART has rigorous requirements for membership. SART members must agree to: 1. Report all their pregnancy data yearly. These data are subject to validation (a modified audit) by a team comprised of the CDC and the SART validation committee. This validation includes a site visit to the SART member’s clinic and review of the medical records. 2. Embryo laboratory inspection and certification every two years by an outside agency, usually the Joint Commission of Hospitals (JCHO) or the College of American Pathologists (CAP). 3. Abide by all practice, laboratory, ethical, and advertising guidelines. 4. After January 1,2000 all new practices must have a board certified reproductive endocrinologist as medical director.
Patients seeking IVF services can be reassured that a SART member has satisfied these rigorous requirements.
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What is validation?
Federal Law requires the publication of assisted reproductive outcomes from all clinics providing such procedures in the United States. Validation is the process whereby, through random sampling, the veracity of the entire dataset to be published is established. This process is performed by the Validation Committee in conjunction with the CDC. The Validation Committee is composed of fourteen professionals from both SART and non-SART member programs. Sites to be visited (currently forty) are randomly selected by the CDC, with site visits performed by teams of two Validation Committee members. Currently, about twenty variables are validated from 50 randomly selected cycles. Additionally, all live births reported by the clinic are validated. The data collected from site visits are compiled, and reviewed jointly by the CDC and the Validation Committee. Programs are notified regarding the overall outcome of validation and their specific program results.
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