The embryo beauty pageant and why your eggs don’t care if you yoga.

May 24, 2010Carole 8 Comments »

Sometime during your embryo’s time in the lab, your embryos will get their very first report card. Seems like too much performance pressure already, doesn’t it? Pretty soon, elite preschools will probably be asking applicants for embryo reports.

Depending on the program, you might get an embryology report on day 2 , day 3 or day 5 of culture. In my lab, it was a fertilization report, report on day 3 and a final report on the day of transfer which was day 5 of culture for us. We used the Gardner scale where the best embryo  received a grade of 4, the “least best”received a grade of  1. Other labs do it exactly opposite, where the best is number 1, the least best is 4.

Regardless of scale, embryologists like embryos with cells that are nice and round, equal in size without any cell fragments between the cells. Embryologists are always being asked by their physicians, “Which embryos are best? Which embryos will get my patient pregnant?”, so we’ve come up with these scales and methods which are really just complicated beauty contests. Although we try to be extremely objective in our evaluation, it’s still a subjective method. Some technicians grade harder than others. Sometimes knowing the couple personally makes us “grade on a curve” because we know you’ll be upset if all your embryos get a bad grade.

The truth is, appearance is only very roughly correlated with implantation and pregnancy. The most important factor has nothing to do with appearance and everything to do with maternal age.

As a young embryologist, that lesson was taught to me by two of my first IVF cases. Our patient was just over forty years old and we had some trepidation about how she might do with her stimulation, but she produced four perfect embryos which we transferred on day 3. These embryos were text book perfect, no fragmentation, perfectly round cells, absolutely lovely eight cell embryos on day 3. We were all so pleased to share the good news with her before the transfer.

Around the same time, we had another patient who was thirty years old. She had eleven embryos and every single one looked terrible. Cells were irregular and more than half were fragmented. It was so bad, I couldn’t decide on some of the embryos if the cells were really just large fragments. When I was asked which embryos were the best to transfer, I really had no basis for selection. All looked terrible and probably not viable based on the embryo grading scale. Everyone felt bad. With the not-so-scientific theory that the embryos would be better off inside the patient and the patient’s consent, ALL -gulp!- eleven  embryos were transferred. We tried to put a good face on it, but we had little hope for this patient getting pregnant.

Who got pregnant? You guessed it. Our forty-year old with the “perfect’ embryos had a negative pregnancy test. The thirty year old got pregnant and delivered a beautiful baby girl. And I mean Gerber baby beautiful. Those two cases taught me a very important lesson. Age really does matter. Figure 14 on the 2010 CDC summary report  (copied and pasted below) shows the correlation between age and pregnancy rate. This chart is largely unchanged in 2013.

http://blog.longislandivf.com/wp-content/uploads/2013/09/LIIVF-9-9-13-blog-table-1-use-first.png

 

For twenty nine year olds, the pregnancy rate was about 50%, with live birth rate of around 45%.  At the other end of the age scale,  for women who were older than 44 years of age, the pregnancy rate was less than 5% with a live birth rate of under 2%. It’s depressing, isn’t it?

I am old enough not to be ashamed to call myself a feminist but we ignore biology at the risk of being heart broken. As I mentioned in an earlier post, I hate to see forty somethings who are very successful in their professional life and take great  care of themselves, staying fit, doing yoga, watching their weight suddenly realize that their eggs are not going to cooperate with their life plans, in spite of all their hard work. The Hollywood celebrity birth parade makes it look like forty and fifty year olds can get pregnant with ease using IVF. The truth is, they can become pregnant easily with donor eggs, just not their own.

Okay, so why am I telling you this? Two reasons. First, don’t get hung up on the embryo report card. It really is not that great a predictor of pregnancy. Second, if you are over forty, look at the numbers and be kind to yourself. Don’t go in for endless rounds of IVF because your embryos keep getting A’s on their report cards. It is possible that you could be happier making other choices (donor egg, adoption) and get that first real report card from your kid’s teacher just that much sooner.

© 2010 – 2015, Carole. All rights reserved.

8 Responses to this entry

  • AKD Says:

    Here from LFCA. I’ve gone through IVF once (resulted in severe OHSS, so we had to freeze the embryos), and two FETs. I just wanted to tell you how awesome this blog is, and how helpful it is to those of us with infertility issues. I’ve pored over the CDC’s website and individual studies so many times, but you sum up information so much better. What a great resource.

  • Carole Says:

    Angie, Thanks so much for your kind comment. I am so glad to know that the CDC information was useful to you-and thrilled that someone out there besides my dear family is reading my blog! 🙂 Best of Luck on your treatments!!

  • Melody Says:

    Here from LFCA, but when I read your bio I of course had to do a little more digging and discovered that you are the Director of Embryology at the center where I had my two IVFs! Thank you for putting this information out into the blogosphere. It is SO appreciated.

  • Carole Says:

    Melody, thanks for your kind comment, but I feel I need to set the record straight. Since January, I have been self-employed as a medical writer. My full time position was eliminated and replaced with an off-site consultant lab director. A sign of the economic times, I suppose. In any case, it frees me up to do what I like best- arming patients with knowledge to help get through this difficult time in their lives. I welcome constructive criticism too-and suggestions for areas you’d like me to investigate and talk about.

  • Emily Says:

    Here from LFCA, but when I read your bio I of course had to do a little more digging and discovered that you are the Director of Embryology at the center where I had my two IVFs! Thank you for putting this information out into the blogosphere. It is SO appreciated.

  • Day 3 vs. Day 5 Culture | Fertility Lab Insider Says:

    […] blastocyst stage can be used as a criteria for embryo selection. You may remember an earlier post “The embryo beauty pageant and why your eggs don’t care if you yoga”, discussing the limited utility of appearance-based predictors of embryo viability and pregnancy. […]

  • Grace Says:

    I enjoyed this post so much and love your examples. Does this discrepancy with implantation perhaps depend also on the age of the woman’s uterus? I’m reading that more problems are likely to occur with age, such as fibroid growth, polyps, adenomyoma.

  • Carole Says:

    Hi Grace,
    Yes, with age comes the increased risk for some of these uterine abnormalities which can interfere with uterine function. However, in the absence of these abnormalities, an “old” uterus can perform as well as a “young” uterus. You have probably heard of cases in the news where post-menpausal women (grandmothers) have used their uterus to carry their daughter’s embryo if the daughter was born without a uterus or had a hysterectomy. So unlike the ovaries, uterine function is more resistant to aging. Thanks for reading the blog. Best Wishes, Carole

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