Understanding the Gardner blastocyst grading scale

December 18, 2011Carole 207 Comments »

Recently one of my readers had a question that I think many patients who go through IVF may have. She wanted to understand what blastocyst grading means in terms of embryo quality and then, obviously the implications for her  chances of pregnancy. Her question was: ” I just had two expanded blastocysts transferred on day 5.  Both were graded CC.  With my last IVF we did a SET with expanded blastocyst, grade BB that resulted in a chemical pregnancy.  In your mind is it more important that they are expanding blastocyst or the grade? (would an early blastocyst grade AA be better)….should we consider implanting on Day 3 (when we had 8 embryos still around)?”

Probably the most widely used blastocyst grading system is the David Gardner system which separately judges the functional milestones the embryo reached (namely how expanded the embryo is and its progress in hatching out from the zona pellucida (1-6 with 6 being completely hatched) and the number of cells in the inner cell mass (A-C) and trophectoderm layer (A-C where an A means the greatest number and most tightly organized cells).

What is a blastocyst? A blastocyst describes an embryo stage reached usually after about five days of development post-fertilization. It has about 50-150 cells and has started to develop specific regions with different cellular destinies. The blastocyst is working hard; pumping fluids towards its center, creating a fluid-filled center and expanding like a water filled balloon. The inner cell mass is a clump of cells  protruding into  the middle of the fluid-filled cavity. This inner cell mass will continue to grow and ultimately will be the source for all the cells of the future baby. The trophectoderm cells line the inner surface of the zona pellucida (the glycoprotein shell around the embryo) and play a supporting role, supplying cells to form the fetal part of the future placenta. So the grading system takes into account how much progress the embryo makes in hatching from the “shell” and also how richly endowed the inner cell mass and trophectoderm are in terms of cell number and quality. More expansion is better than less and more cells are better than fewer cells.

The expansion grade scale ranges from 1 (least expanded) to 6 (completely hatched).

Grade 1: the fluid-filled cavity takes up less than half the space of the embryo.

Grade 2: the fluid-filled cavity takes up more than half the space of the embryo.

Grade 3: the blastocyst cavity has expanded into the entire volume of the embryo, pressing the trophectoderm cells up tightly against the inside of the zona.

Grade 4: Expanded blastocyst, where the blastocyst has increased beyond the original volume of the embryo and caused the zona pellucida “shell” to become super thin.

Grade 5: Embryo has breached the zona and is hatching out of its shell

Grade 6: Embryo is completely hatched.

So the embryo is given a number grade (1-6), followed by a letter grade for the inner cell mass and then the trophectoderm (A,B or C).

For the inner cell mass:

A: Many cells, tightly packed

B: several cells, loosely packed

C:  very few cells

The trophectoderm grading goes like this:

A: many cells, forming a cohesive layer

B: Few cells, forming a loose layer

C: Very few large cells.

So a blastocyst with grade 5AA is partially hatched with many cells in the inner cell mass (cells for the future baby) and many tightly packed cells in the trophectoderm.

One thing to remember is the grading also represents a continuum. A healthy blastocyst starts out unhatched with a small space and few cells, then progresses to a hatching blast with many cells. When we pick a blastocyst to transfer on day 5 of culture, we preferentially pick the most advanced embryos that seem most “eager” to implant. That doesn’t mean that a blastocyst with a lesser grade won’t implant. They do. Remember we are looking at  a snap shot of embryo development and not all embryos in a group started the developmental pathway at the same instant.

A picture is worth a thousand words.

Here are a group of expanded but not yet hatched blastocysts (grade 4AA).

 

 

 

 

 

 

 

 

 

Here is a partially hatched blastocyst (grade 5AA). You can see the clear zona pellucida shell barely attached to one end of the blastocyst.

 

 

 

 

 

 

 

 

For more pictures of  graded blastocysts in various stages of development, look at these  (copyrighted) embryo pics  at this link  http://www.advancedfertility.com/blastocystimages.htm . These pics should help clarify the grading system.

Regarding my reader’s question of whether the degree of expansion or whether the cell number is more important in a successful implantation and pregnancy…well, it’s not usually a question of one or the other. In a healthy embryo, they tend to go together. Typically, as the cell number increases, so does the level of expansion.  What is a deal killer is if we don’t see a clump of cells corresponding to an inner cell mass because that means that none of the cells in the embryo have been allocated to make the future baby. Other than that, there is a lot of flexibility in the embryonic program and I wouldn’t despair if my blastocyst had a lesser grade. I have seen morulas (the stage before blastocyst) transferred on day 5 result in pregnancies so our preconceived notions of where an embryo must be on day 5 are not always predictive. However,  if an embryo is delayed by more than a day- say 8 cells on day 5, it probably will not be result in a pregnancy because it has likely stopped developing.

Hope that helps demystify embryo grading. 🙂 Best Wishes.

 

 

© 2011, Carole. All rights reserved.

207 Responses to this entry

  • Carole Says:

    Hi Jatulah,
    It is tempting to do an early pregnancy test but it can be misleading. It is better to follow your doctor’s instructions for the timing of the test so you can have more confidence that the test result is correct. Good Luck!! Carole

  • Fonwol Da Says:

    Hello Carole,
    Thank you for your reply. My uterine lining was 8mm, (Dr said anything above 1mm was fine). Our weakest link has always been my husband’s low sperm count. Are there any drugs/supplements you think, my husband can take to increase his sperm count and improve our chances?

    What would be a good count, that would likely produce good quality embyos (AA), on fertilisation?

  • JK Says:

    Hi Carole,

    I went through several failed IVFS (started at 42 and had numerous eggs but only chemical pregnancies) until I got pregnant @45 via 1 donor egg. Very healthy pregnancy and super healthy son. Yesterday I transfered 1 donor embryo 5AA and 1 my own embryo. 5BB day 5 blasts. What do you think my chances are of pregnancy or even twins? I’m a healthy marathon runner but I know that only helps so much in this arena. Husband healthy too.

    Can you also answer the myth of bedrest to implant. I’m handling my 17 month overactive son so little chance of that.

    Thanks much,
    JK

  • Fonwol Da Says:

    Hello Carole,

    Just a bit more information. My husband’s last SA, carried out on 15/04/2015:

    Andrology Details:
    Analysis:
    Volume (ml): 1.6
    Density (M/ml): 0.18
    Total Motility (%):

    Normal Forms (%)

    Thank you. Greatly appreciate your feedback.

  • Carole Says:

    Hi Fonwal Da,
    You might be interested in reading this previous post on thin uterine lining: http://fertilitylabinsider.com/2013/10/q-from-u-causes-of-thin-uterine-lining-and-treatments-to-improve-receptivity/ There is data to support the idea that 9 mm uterine lining or thicker is associated with better implantation than thinner endometrium. Here are some previous sperm posts that should answer some of your questions: http://fertilitylabinsider.com/?s=sperm+quality
    Wishing you much good luck!! Carole

  • Carole Says:

    Hi Fonwal Da,
    Here is a previous post with info on what a normal sperm analysis looks like and implications:http://fertilitylabinsider.com/2010/06/semen-analysis-uses-and-limitations/ Good Luck!! Carole

  • Carole Says:

    Hi JK,
    It is hard to predict but your best chance is with your donor egg, because of your maternal age. Maternal age trumps everything else because the quality of eggs declines with age regardless of ANY other factor. It is counter-intuitive but good living (and being athletic) has nothing to do with fertility. The opposite extremes of obesity are bad for infertility because they interfere with the hormonal balance–but extreme thinness/athleticism has no beneficial effect on fertilization/implantation. When you are pregnant, however, your excellent cardiac health becomes beneficial to you and your baby. I think bed rest has been shown to be not be terribly beneficial- the embryos can’t fall out. I would discourage marathon running on the day of the transfer or other extreme activities because you want good blood flow to your uterus. Congratulations on your healthy son and I wish you much good luck with this transfer!! Carole

  • hayley Says:

    Hi Carole

    i had a 6 day thawed blast transferred today, graded 5ab before freeze. when it defrosted my embryologist said they could nt regrade it as it had hatched, then collapsed. If they gave it a few hrs it would re-expand but they said it made no difference to transfer so went ahead at that point.. is that correct?

  • Anonymous Says:

    Carole,

    Just an update – got my 2ww HCG results today. Prego with 313 HCG! Last pregnancy was only around 27. Thoughts?

    JK

  • Carole Says:

    JK-
    That is an excellent first beta!! Wishing you much happiness going forward! Congratulations! 🙂

  • Carole Says:

    Hayley,
    Yes, that was the right thing to do. Blastocysts do tend to collapse and re-expand, sometimes more than once. Waiting for scoring again is not a useful exercise because the scores are not terribly predictive. Your embryo is much better off inside you. Wishing you much good luck!! Carole

  • Lindsay Says:

    Hello, we just had an unsuccessful first IVF attempt. They retrieved 15 eggs, we did 7 regular and 8 through ICSI. Only 4 through ICSI initially made it, but only 1 actually made it to a blastocyst. It was a CB embryo. We did a frozen transfer, but it did not work. My doctor says he believes I have low quality eggs, and my husband’s sperm will need assistance through ICSI to break through the egg’s shell, all this based on none of my eggs making it to a blastocyst except one through ICSI, and that was a “low grade” egg. He is suggesting egg donation. My questions are; Do you think we should get a second opinion? Or do you think we should try IVF again? We have been trying for 4 years with no signs of a pregnancy whatsoever. All the testing we have gone through has shown we are both very healthy 33 year olds.

  • Carole Says:

    Hi Lindsay,
    Yes, I would get a second opinion- especially before I would try egg donation. Everything you describe could also be a result of poor lab quality. I would find the clinic with the best pregnancy rate that you can get to and I would go there for a second opinion. If you are in the US- go to the SART website http://www.sart.org/find_frm.html, and search the pregnancy reports for the clinics near there.Compare these rates to the Average national rates https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0 Don’t go to a clinic unless their rates for your age group are at least as good as the national average, if not better. Good Luck!! Carole

  • Katy Says:

    Hi Carole

    This is extremely informative, thank you.

    I have just had a failed fresh cycle after transferring a 6AB day-6 blastocyst. We had CGH testing on day 5 and 4 euploid blastocysts (the other 3 are frozen – 6BA, 6BB and 3CC).

    Everyone was so optimistic at our transfer, the negative test is a shock. I am 34 and our only known problem is semen quality (we used IMSI this round). If we move to FET, is there anything we can do to improve implantation odds or is it likely that there’s and underlying problem with uterine environment/receptivity?

    It’s difficult to find statistics on euploid hatched blastocyst transfer, and so to evaluate if this is simply bad luck.

    Huge thanks in advance for your thoughts.

  • Carole Says:

    Hi katy,
    I would not be too discouraged at this point. You still have a lot going for you- having euploid blastocyst embryos is half the battle. There is some data to suggest that FET cycles may work better than the fresh transfer for some women- especially if their estradiol levels were on the high side. The endometrium prefers a more nuanced hormonal preparation then the FSH-sledgehammer that is used to maximize eggs at retrieval. I think it is pretty hard to diagnose ueterine receptivity problems if the lining is the right thickness-so I wouldn’t assume that you have a receptivity problem that can’t be fixed by a more focused, nuanced endometrial preparation- like you will have for an FET. I would caution you not to throw all your remaining embryos back at once just because it was a negative result this time- since they are all euploid -they could very well all implant next time. Although this is a set back and feels terrible, I think the odds are still with you. Good Luck !!!

  • Katy Says:

    Carole, thank you so much for your reply – it is really so kind of you to help women in the way that you do.

    The nurse at my transfer did mention that my ovaries were still quite enlarged, and I wondered if I was still not in the best shape – I was still very bloated the day before. This was actually our 3rd fresh transfer (which is why the CGH), but the first two cycles were non-ICSI/IMSI, and the embryo quality seems to have improved quite a lot thanks to IMSI this time. But it is, of course, always possible to have more than one issue!

    We have always been pro single embryo transfer, but it’s always good to have encouragement on this position, as friends who have been through IVF have invariably had more than one put back. I am actually an identical twin, and love it, but have always been aware of the associated risks. We would really just give anything for one healthy baby. Incidentally, my twin conceived first month trying last year, which has been both reassuring and tough!

    Anyway, I will see what the doctor says re immunes, blood supply and anything else; but it’s very comforting to hear that even something as subtle as a gentler preparation could make a difference.

    Thank you again – we are very appreciative of your help.

    Katy

  • cynthialee Says:

    Hi Carole,

    I am in total despair. I just found out that I had my second failed FET (it was a 6BB0). Last year I had my first FET (5BB0) and it was a failed FET as well. I have immunes issues, high cytokines but the levels have gone down to approximately 34, I also have elevated NK cells, but has been on intrallipids therapy the last few months to lower both. I have also done LIT treatment. Carole, I have two questions if you can please kindly help me in answering them…
    1) The failed 6BB0 and 5BB0 were from the same cycle (they were PGS tested and came back normal). They went through invitrication thawing too. Since both of these were from the same retrieval, could it be due to this fact that they failed (since they were from the same retrieval batch)?

    2) I am turning 38 in a few weeks, I am torn on whether or not in doing another new retrieval and PGS testing (due to my age) or to proceed with transferring my one remaining 3BBO PGS normal embryo from an earlier egg retrieval cycle? I did my 2 prior retreivals at age 36-37 (on average it was 5 blasts send for PGS testing and 1 or 2 came back normal – one was the 3BBO in my first retrieval and two (5BB0 and 6BB0) on my second retrieval).

    Any insight will be greatly appreciated!

  • cynthialee Says:

    I’m sorry Carole, I don’t think I explained my situation clearly in my previous post (I was crying non-stop as I was typing away).

    The 3BB0 was done in my first IVF attempt. The lab waited until Day 6 to let it “develop” more before it went through PGS testing. The 3BB0 was frozed and the PGS results came back normal. In this IVF attempt, I had 12 eggs that fertilized, but as the days continued only 5 made it for PGS testing and only the 3BB0 came back normal (I was 36 at the time).

    The 6BB0, 5BB0 was done in my second IVF attempt (I did back to back IVF’s one month a part from each other). Again, the lab waited until Day 6 to let it “develop” more before it went through PGS testing. The 5BB0 and 6BB0 were frozed and the PGS results came back normal. In this IVF attempt, I had 11 eggs that fertilized, but as the days continued only 5 made it for PGS testing and the 5BB0 and 6BB0 came back normal ( 36 years old still – a few weeks shy of 37).

    Hindsight, not really sure if I was too quick to do my IVF #2 at the time and as a result caused the 5BB0 and 6BB0 not to implant because I just went through IVF#1 the prior cycle.

    My Doctor has classified me as Unexplained after my first failed FET. I feel that I am a lost cause at the moment esp. with the news today of my failed FET #2.

    Thanks in advance Carole! Any Help/Advice is greatly appreciated.

  • Carole Says:

    Hi Cynthia Lee,
    I am so sorry you are having such a difficult time. It sounds like about 10-20% of the embryos in each cycle are normal. Unfortunately, this percentage won’t get better the older you get- IVF is not working very well for you and may not be worth further investment. I would definitely transfer the remaining embryo at some point. I guess the real question is should you try another IVF cycle to get a couple more embryos. The answer to this question is less a technical one but has more to do with how much more you can bear in terms of emotional and financial reserves on a procedure which is not working well for you. Bankrupting yourself with IVF cycles is a bad idea and leaves you with few options. Adoptions are not inexpensive either but that at least is a sure thing. You could look into embryo transfer of donated embryos as another alternative- some clinics offer this. Obviously, none of these other options are your first choice to have a family but it might be time to take some time for yourself and decide what you really need to be happy, not next week or next month but 5 or 10 years from now. It may or may not mean a pregnancy, but it might very well mean a son or daughter in your life to nurture and raise- just maybe not the way you’d planned originally. IF you at the point of despair, it is time to stop, give yourself a break from IVF and think about the big picture. The answers you find might well surprise you. I wish you Much Good Luck with whatever path you choose. Carole

  • Tara Says:

    Hi!

    Just wondering if you can provide some insight.. I am 34, my husband is 37 and we have unexplained fertility. All of our tests have come back normal. I had 3 failed IUIs, and am just in my first ivf cycle. I did my egg retrieval last week, 15 retrieved, 13 fertilized (7/8 with icsi, and 6/7 with ivf).. We ended up 5 blasts 5AB, 5BB, 5BC, 2CC, and 1BB from icsi.. I know one embryo transferred is preferred, I was thinking to transfer the 5AB first, and if that doesn’t take, then do the 5BB and 5BC together. Not sure about the lower grade ones yet.. What do you think? Is there hope for those low grades?

  • Carole Says:

    Hi Tara,
    The higher scored ones will likely be better but scores are not the end all- we have been surprised by “ugly” embryos that make beautiful babies! Your choice of first ones to transfer sounds very reasonable. Good Luck!!Carole

  • Vivian Totten Says:

    Hi,

    I was wondering if you can please provide some insight. I am 39 and have gone through two unsuccessful Frozen Embryo Transfers (PGS tested) and have no more embryos.

    My husband and I are deciding whether we should continue with a fresh IVF cycle, Frozen Embryo Transfer (but no PGS)? There is little studies on PGS but when I spoke with another fertility doctor who don’t do PGS, they said they don’t advise on it because although it’s taking a small amount of cells from the embryo for PGS testing, however, that can still damage the embryo. And PGS testing results aren’t 100% accurate, sometimes abnormal embryos are indeed normal embryos or vis versa.

    Any guidance would be greatly appreciated as well as any insight on PGS testing.

    Regards,
    Viv

  • Ashley Says:

    Hi Carole, I just had a failed cycle using donor eggs. It was a 4bb 5 day blast. Here is what I have frozen:

    2BB
    MN EBB (MN = multinucleated)

    The doctor suggested to be more aggressive and put both in next transfer. However I have lower uterine segment scarring from previous C-sections. What are your thoughts on the quality embryos that I have remaining? Especially the second one? I haven’t found any grade info on MN EBB. What does that grade even mean? Also, what would you recommend for me to do? Put them both in or just one? If only one then which one should i have transferred?
    Thank you!

  • Ashley Says:

    I should have been more specific about my lower segment scarring. The thinness was measured at 2.4mm of the lining. I was told it should be thick like steak and it’s very thin. I considered surrogacy but really want to try this on my own in spite of the risks. I have researched uterine rupture and such a small percentage of pregnancies before labor end in rupture so I think I will be fine if I’m monitored closely and don’t get close to my due date before I have a c- section. What are your thoughts?
    Thanks!
    Ashley

  • Carole Says:

    Hi Vivian,
    PGS does involve removal of some cells from the embryo but the effect of that is minimal if the biopsy occurs on day 5 – when you have over 100 cells in the embryo compared to day 3, where you might have only 8 cells. On day 3, taking more than one cell can be problematic because you are taking a bigger percentage of cellular tissue. On the other hand, if you take 2, 5, even 10 cells from the trophectoderm of the 150 cell embryo, the embryo probably won’t miss these extra-embryonic cells which go toward making the future placental tissue. So timing of the biopsy is very important and also , of course, the skill of the embryologist. So if it was me, I would do biopsy on the day 5 embryo, freeze the embryo, wait for results and transfer all the normal with a future FET- assuming I can find a lab that has a proven track record of routinely getting patients pregnant after day 5 biopsy, freeze and transfer. Yes, PGS results can be inaccurate (perhaps as much as 10% error rate) – which is also why it is better to sample more cells than just one- biopsy on day 5 instead of day 3- which increases your chances of good signal.
    The PGS issue may be a distraction. Some docs don’t like doing PGS on women over age 35 because it is more likely they will have nothing to transfer- which makes the patient disappointed in the doctor – without any chance of pregnancy. Docs would be happier to transfer some embryos- which might have to be untested in older women in order to get something to transfer- so than if the cycle doesn’t work- not their fault- you got your transfer after all. At some point, I would question how much more you should put yourself through with IVF and PGS. You can, of course, do more cycles, with diminishing returns each month as you age, and you may get pregnant- but the odds are not in your favor with using your own eggs, as you are almost 40. If you still have lots of emotional and financial reserves, maybe that is the way to go- you can be sure you used every last possible egg. On the other hand, it may be time to think about other options for being a parent that don’t rely on your own eggs and PGS testing. Other options that are more likely to work for you- like donor eggs or transfer of a donated embryo from a younger patient (the uterus is more forgiving of aging than the ovaries) , or traditional adoption. There are no right or wrong answers here, just give yourself the space to consider what is best for you and your future family, no matter how you build it. Wishing you Much Good Luck with whatever you decide. Carole

  • Carole Says:

    Hi Ashley,
    I really would speak to an obstetrician who specializes in high risk pregnancies to get a recommendation about whether more than one embryo is a safe option for you. I think most doctors would agree that multi-nucleated embryos should not be transferred.I would highly recommend that you seek a second opinion before your next transfer. Good Luck!! Carole

  • Zuza Says:

    Hi Carole,

    First of all, thank you so much for all the precious information on this site.

    We had 11 eggs from a young Donnor (22yrs) and my husband’s results were just perfect.
    On day 5 we had four blasts: 1AA, 1BB, 2BA, 3AA.
    On day 6 we got two more: 3BC and 4BB.
    Mine and Donnor’s blood type is 0. I read somewhere that woman with this blood type have more problems with quantity and quality of the eggs – is this true?

    We had first FET with 3AA (from day 5 ). Everything seemed right (endo biopsy during previous cycle, lining over 9mm). But no success 🙁
    I am worried because if 3AA didn’t take, the remaining ones are lower quality …. Could the 9 hour fligh five days after the transfer affect the outcome? (I didn’t go thru the security gates – told them I was pregnant) Our clinic is in Europe so we have to travel back afterwords. What would be the best time for travel, how many days after transfer?
    Or does it make sense to consider moving frozen embryos to US … but this probably would be too risky- have you heard about embies traveling on the plane?

    Now, we are getting ready for the next FET and this time we decided to transfer two.
    I understand that even though 4BB (from day6) is the most advanced, we should select two from the ones achieved on day 5 – is 2BA and 1AA right choice?

    Would you recommend Assisted Hatching? – our clinic almost always does it…

    And one more question: what do you think about embryoglue?- worth trying?

    Many thanks in advance,
    Zuza

  • Carole Says:

    HI Zuzu,
    Regarding blood type: I don’t know of a correlation between O type blood type and egg quality. Rh factor mismatch between donor and the woman carrying the child may cause problems but A, B and O blood types are not an issue– unless parents want to ‘match” the blood type of their child so that blood type is “plausible result” from the marriage- ie. you do not want to reveal that the baby is from donor egg. I think transparency is the best idea but here is info about blood type http://www.pved.org/bloodtype.php. I don’t think the flight affected your outcome. Yes, you had some stress but stress is common to the human condition for thousands of years so unless other things were also going wrong, i don’t think the flight alone can be enough. Embryos are shipped around the world all the time. The biggest problem is not in transit- it is that the recipient lab won’t have the necessary experience to successfully thaw and recover the embryos from the freezing containers. I would defer to your clinics recommendation of which embryos to transfer because they know how patients like you with embryos like yours do at their clinic. Likewise, with embryo glue- if they use it with success at their clinic- go for it. I wouldn’t ask them to try anything new because they will be inexperienced with it and it might not go well. Good Luck with whatever you decide!! Carole

  • Louise Says:

    Hi,

    I am 42 and recently did an IVF cycke with PGD. I got two blastocysts by day 6 . On day 3 there had 8 cells and by day 5 were blastocysts but not hatching so had to go to day 6 as of course have to be hatching for biopsy. On day 6 one was hatching and abke to be biopsied and the other wasn’t hatching enough but was suitable to freeze. My Dr said he wouldn’t place must hope on the day 6 untested frozen embryo because it was slower at developing. However would the embryologist have frozen it if it didn’t look viable? I am with a very reputable clinic with good stats. I am a bit disheartened by the comment as I think why even bother growing them to day 6 if they have such a low probability of success.

  • Carole Says:

    Hi Louise,
    One confounding issue is that the clinic you use does not biopsy un-hatched blatocysts. Not every clinic requires the blastocyst to hatch before biopsy. There is a technique to biopsy the unhatched blast but it requires a little more skill and training for the biopsy technician. I wrote a blog post on this topic http://fertilitylabinsider.com/2012/03/new-series-q-from-u-biopsy/ . Embryos are routinely frozen based on meeting “appearance” criteria so yes, they can freeze untested day 6 embryos. In this clinic, they are taking failure to hatch spontaneously by day 6 as evidence of poor quality. I don’t understand this because some clinics routinely transfer day 6 blasts- hatch or unhatched. They are using “slow” progression to hatch and probably your maternal age as a disqualifier for this embryo- when they could use genetic testing results if they would only learn how to biopsy unhatched blasts. At this point, you have little choice but to follow their guidance on what usually works in their lab. If you do another cycle- I would seek a clinic that routinely biopsies all embryos that reach blast stage – hatched or unhatched. Good Luck!! Carole

  • Louise Says:

    Carole – thanks so much for your reply. I just thought it was standard that all clinics would only biopsy hatching blasts. It’s good to know that’s not the case. The embryo that was tested came back chromosomally abnormal so I guess I’m even more pessimistic about the untested one although I guess just because the eggs were from the same ‘ batch’ doesn’t mean they are both abnormal. I will definitely do some research with other clinics and their criteria for biopsy.

  • Zuza Says:

    Hi Carole,

    Thank you for all the info about blood types… it made me wondering about my Rh. It is ” – ” and my husband’s is “+” . Last year we lost pregnancy around 6-7 wks. Is it possible that it created a problem for future attempts?

    Regarding the long haul flight, it is not stress that I am worried about, it is the pressure, radiation from the sun etc. So I imagine if embryos are frozen before they hatched , maybe they are safer on the plane in a frozen stage in a container rather than in my belly… I guess I am overanalyzing but we are trying for so many years already and I want to believe that one of those embies will be willing to stay with us for good. So I want to crate the best conditions possible…
    You confirmed that embryos are shipped around the world – thank you! I found the company that do this professionally from clinic to clinic – what I read on their website looks promissing ( my husband is contacting them for details)

    Thank you!
    Zuza

  • Carole Says:

    HI Zuzu,
    You need to follow up with your RE/obstetrician about the rH factor issue. Here is more on this topic: http://americanpregnancy.org/pregnancy-complications/rh-factor/ I think the plane ride for your embryos – either in your uterus or frozen in a transport carrier – is not something to worry about too much. Good Luck! Carole

  • Louise Says:

    Hi Carole – in my first cycle with ICSI I started with 17 mature eggs but overnight 7 of them ‘disintegrated’. The scientist said ‘ sometimes they just don’t like the needle’. Was this due to poor egg quality since I’m 42 or could it also have been due to the skills of the technician ini injecting the egg? I’m inclined to think it’s quality as it’s difficult to imagine that 7 would have been injected incorrectly.

  • Carole Says:

    Hi Louise,
    I have encountered the rare patient who had extremely fragile eggs which could not tolerate injection- so that is possible- I am not sure if older age is necessarily a factor in fragility. It is also possible that a poorly trained or inexperienced technician had a really bad day and had technical problems–but if I am reading between the lines- 10 eggs injected well and fertilized? -which is a good outcome for any cycle. Generally speaking, most cycles can expect a good outcome of 10-12 mature eggs even if way more were retrieved– so getting 10-12 injected and fertilized is a great outcome. Good Luck!! Carole

  • Louise Says:

    Carole,

    Thanks. That’s right I had 17 mature and suitable for injection , 10 fertilised ok (but only 7 still going by day 3 and 2 by day 5). My fertility specialist said the fact that 7 had disintegrated after being injected meant my eggs were ”very poor quality’. Hopefully next cycle the same thing won’t happen.

  • Hannah Says:

    Hi Carole,

    I was hoping you could help me out with a couple of questions…. I am 35 years old from Australia and due to premature menopause we have embarked on a donor egg cycle in the USA. We had our egg donation cycle earlier in the year and transferred one 6AA PGS normal, fresh embryo. Unfortunately the embryo split after transfer and this resulted in twins. As it was an uneven split my pregnancy ended in miscarriage at 8 weeks.
    We are planning on heading back to the USA for a FET in late September. We have 5 embryos left which have been cryopreserved via vitrification. All have been PGS tested and are normal. We really want to transfer a female embryo but the only female embryo is graded 6BB. We are a little concerned that perhaps we should be going for a higher quality embryo – we have 6AA, 6AB (x2) and 6BB (x2), however we have read a lot about the embryo grading being irrelevant if the embryos are PGS normal. Can you confirm if you believe this is correct?We are also concerned that perhaps a lower grade embryo has less chance of surviving the thaw process?

    Many thanks in advance!
    Hannah

  • Carole Says:

    Hi Hannah,
    I think there is little predictive difference in scores in the high end of the range- with A’s and B’s. Yes, the PGS normal is a better indicator of a good embryo than grading by itself. My very first IVF baby from my clinic work was from a highly fragmented embryo with a poor score- and she was a lovely normal baby!!- So I think you should follow your heart and transfer the girl embryo. Good Luck with whatever you decide!!! Carole

  • Hannah Says:

    Hi Carole,

    Thank you very much for your response. I really appreciate it. We will definitely go with our heart and transfer the female embryo.
    Can I check something else with you…. Do hatching blastocysts generally survive the freeze/thaw process as well as unhatched embryos?

    Thanks again,
    Hannah

  • Carole Says:

    Hannah,
    Yes, they can survive as well but they may lose their “shell” along the way since they are already hanging out of it. However, with good technical skill- the embryo should be transferred to the uterus without too much difficulty- and then it is ready to implant. Good Luck!! Carole

  • Hannah Says:

    Thank you so much for taking the time to answer Carole. I really appreciate it! Hannah

  • Gunelle Says:

    Hi Carole, thanks for this informative site. Can you tell me what would be the minimum grading for a blastocyst to be considered “high quality”?
    Like minimum expansion grade 4? Or 3? And definitely A or B.
    My one clinic has promised me another embryo of high quality and I’m trying to figure out a reference for what I should expect. The other blastocyst is a 1BC — not very good, is it? (or equivalent, they use slightly different grading system)
    I’m moving to another clinic and they said they don’t understand why the first clinic froze the blast so early (at stage 1). But the first clinic said they always freeze it as soon as becomes a blastocyst, otherwise might degenerate. (But then not a promising blast to begin with? – one wants to see if it gets to expanded, then it’s a trooper.)
    I hope you can provide your two cents soon! Thanks!

  • Carole Says:

    Hi Gunelle,
    The term “High quality” can be used subjectively- what is high quality at one clinic might be average at another- that’s why the drive to standardize scoring. I am not concerned about freezing blasts early- we literally vitrified at every stage from cleavage on. It didn’t occur to us that we couldn’t and so we did even though some clinics we encountered were surprised. The warmed embryos were able to pick up where they left off no matter the stage at vitrification. I am puzzled by their idea that if not frozen at pre-blast stage it will degenerate- it shouldn’t- at least not because of the embryonic stage at freeze. It is also not surprising to have clinic A criticize clinic B and vice versa. There really are a lot of ways to do almost anything in the IVF clinic but to compete, clinics seem compelled to insist there is only one right way- theirs. A general rule of thumb, go with what the clinic has gotten good at. The most dangerous thing you can do is to insist that the clinic try something new on you! Good Luck! Carole

  • Bibi Says:

    Hi Carole, thanks for this site and your patience in answering these questions. I just had a failed FET , had a 5det done on 09/06/15 which resulted in negative. I do have one frozen 6AA from thesame circle.currently on my period ( sorry for the details).my question was, is it ok for me to move forward with my frozen embryo without any problem? Am meeting with my RE on Thursday, I also want him to do another mock transfer just to see if everything is ok in my uterus. Secondly my RE was out of town for a family emergency , so another RE in that practice had to do my transfer. Am still greatful I have a beautiful 5yrs old daughter via ivf with my RE.Will greatly appreciate your respond, thanks in advance.

  • Carole Says:

    Hi Bibi,
    You’ll really need to follow up with your doctor about what approach he thinks will work best- FET right away or wait. Some docs like to see one or two normal periods before they try another FET. My opinion is not really relevant here because your best bet is to let the clinic do what works best for their patients, rather than trying something new- on you- for the first time. Of course, if his plan doesn’t make sense to you, then by all means ask him to explain why he thinks it is best, and you still have the right to decline a plan or approach. Good Luck!! Carole

  • Greg Says:

    Hi Carole,

    We just did a transfer into out surrogate of two 5AA embryos. One was completely hatched and in the few hours after thawing ‘perked up’ greatly. The other was partially hatched and was mostly outside of it’s shell. While the doctor said they both looked great, the embryologist (with questionable bedside manner) seemed more enthused about the completely hatched embryo. Is there a reason to think that the partially hatched embryo is at a disadvantage even though it is a 5AA. Is this something to be concerned about?

  • Greg Says:

    Thank you in advance for your time. 🙂

  • Carole Says:

    Hi Greg,
    No, I don’t think you should worry- sounds like you had two good embryos transferred to your surrogate. Even if the neither embryo was hatched at the time of transfer- you’d still be in good shape. In fact, with those embryos, transfer of one embryo would also have been reasonable – less chance of twins. Good Luck!! Carole

  • Greg Says:

    That’s great news. Thank you for you reply. 🙂

  • Gunelle Says:

    Hi Carole,
    Thank you so much for your response before regarding my concern about what constitutes a high quality blastocyst. Even if there are variables between clinics and it’s subjective, and there is no clear standard across the board – it’s safe to say, isn’t it, that a C grading cannot be considered high quality?! A high quality blastocyst should be a full blastocyst. I’m trying to get some kind of reasonable reference point from professionals in the field. As compensation, the clinic promised me a high quality blastocyst, but are now refusing to define what that is, basically saying they can’t guarantee a high quality blastocyst. Which is contradictory to their promise. Seems they should be able to define what high quality means (to them) — otherwise the term is meaningless, isn’t it? I just want them to produce a high quality blast, not a low grade blast like last time (by anyone’s definition a 1BC cannot be considered high quality? – which is why they offered me another one).

Join the discussion