Q from U: if I transfer this embryo, will I get pregnant?

June 6, 2015Carole 48 Comments »

One question that comes up again and again from IVF patients is: If I transfer this embryo, will I get pregnant?  Patients send me their pictures of embryos and ask me to evaluate them and predict whether this embryo is “the one” that will become their longed for child.

I deeply understand this need to see into the future and gain the knowledge to make the right decision in the present, but it is impossible to predict with certainty an outcome from IVF- especially from a photo. It might help to understand why this is still impossible to do.

Embryologists are tasked to recommend embryos for transfer based on information they can collect while they have the embryos growing in the lab. The 3 main indicators used by embryologists to determine the best embryos are:

1. Does the embryo look “good”? This was the first tool embryologists used but it has been eclipsed by two other tools I’ll talk about in a little bit. Even with only a weak correlation between appearance and implantation/pregnancy success, embryologists were desperate to identify some measures to predict which embryos were most likely to implant and go to term. Some traits –such as an even number of same sized cells at each cleavage stage –seemed advantageous for implantation. Likewise, very little fragmentation of cells also seemed like a good trait for an embryo to have. So regular, even embryos with no or few fragmented cells received higher scores than embryos that had irregular shaped cells and/or lots of fragments. It might have spoken more to our bias regarding beauty- we like symmetrical things and even numbers- and was not based on compelling science that these traits always correlated with pregnancy success. This lesson was brought home to me with two IVF cases very early in my career. One patient was 40 years old with perfect-scoring textbook-looking 8 cells on day 3. The other patient was in her twenties, had a large number of embryos, with each one scoring worse than the next due to large amounts of fragmentation. In fact, it was hard to tell for some embryos if a cell was actually a cell or a large fragment. Based on scoring, we had higher expectations for the 40 year old, but it was the younger patient who got pregnant and this lovely baby was the first IVF baby I was privileged to hold when the patient brought her into the office when she was a couple of months old. This taught me that embryo scores alone could be misleading.

2.  Did the embryo hit certain developmental stages on time or did it stall or lag? This is a functional question which is more directly tied to whether an embryo is likely to keep growing, than an embryo score. Our first real chance to evaluate embryo function was with the advent of sequential culture systems which allowed embryologists to grow embryos for 5-6 days, allowing them to determine if the embryo was able to reach blastocyst stage- the stage just before implantation. We now know that for some patients, a significant number of embryos get stalled at cleavage stages. When embryos were routinely cultured to day 3 to transfer embryos at cleavage stage – and the cycle failed- there was no way to know if this particular embryo would have also stalled out in culture. Now, this embryo has a chance to fail in culture and not be selected for transfer. With the advent of time-lapse continual video monitoring of embryos, and mathematical analysis of these videos- embryologists are able to determine the average times to reaching developmental stages for embryos that go on to implant.  This analysis of an embryo’s functional capacity to grow– has been taken to another level.

3. Does the embryo have a normal number of chromosomes? Chromosomes are twisted strands of DNA that contain all the genetic information passed on from the parents. With only a few exceptions, having an abnormal number of chromosomes is incompatible with continued embryo growth, implantation, pregnancy and live birth. For instance,  Trisomy 21 (an extra Chromosome 21) is compatible with life and these kids are born with Downs Syndrome. With pre-implantation genetic screening (PGS) of embryos, we can tell if an embryo has a normal number of chromosomes. This is a big deal. While aneuploidy testing does not rule out the possibility that an embryo could be harboring smaller stretches of DNA sequences that could doom it along the way- it does rule out really big problems like the absence or addition of entire chromosomes. It is also possible to use pre-implantation genetic diagnosis (PGD)  testing to look for abnormal gene sequences that are harbingers of severe medical conditions later on- but these usually don’t impact implantation potential- in the way that most kinds of aneuploidy do.

The good news is that embryologists have more and better tools at their disposal to evaluate embryos for their potential to implant- and these are certainly evolving and existing tools will improve and new tools will be added as time goes on- but even if your embryologist can find your “best chance” embryo, it still does not guarantee your pregnancy.

IVF is a team effort, not just in the clinic, but also between the patient and the clinic. The physician has to be aware and counsel the patient of other issues that may also be reducing the patient’s chances of conception and a healthy pregnancy.

  • Endocrine problems (eg. thyroid conditions)  that effect reproductive function. If a patient is hypothryoid or hyperthyroid, these conditions must be brought under control first.
  • Insufficient (thin) uterine linings that are inhospitable to embryo implantation. In some cases, a frozen embryo transfer may be more optimal because it separates the IVF case into a ’embryo production” phase in which egg quality and selection can be optimized hormonally and an “embryo implantation” phase in which the uterine lining can be optimally hormonally primed for implantation. The best hormonal protocol for each are often not the same and the lining gets short changed to get more eggs at retrieval.
  • General health of the patient. Patients that are at the extremes of weight (over or under) may have more difficulty conceiving. Patients who smoke also reduce their fertility- this applies to both males and females. There are lots of factors that go into good reproductive health- these are just a few. It is important to share all your medical information with your doctor so they can try to help you optimize your reproductive health before you spend a lot of emotional and financial resources on IVF.

Bottom line, getting pregnant should be easy, but it often isn’t. Even high tech procedures can’t guarantee pregnancy. You can, however,  position yourself for the best possible outcome by finding a highly effective IVF team (look at www.sart.org for  best pregnancy rates in your area)  that will work with you to diagnose the problem (look for good two-way communication between the patient and clinic), grow and find the best embryos to transfer (look for a good lab that uses modern tools) and helps you optimize your fertility before you even get started (good physician practice).

I have a lot of faith in patients to make the right decisions if they have all the information they need along the way. I choose patient education over a crystal ball any day to get a happy answer to the question: Will I get pregnant if I transfer this embryo?


© 2015, Carole. All rights reserved.

48 Responses to this entry

  • 2ndbabycurious Says:

    Hi Carole,
    Thank you for your explanation about the factors involved in the success of a blastocyst. This is helpful!
    We did preimplantation genetic screening of all embryos last year, and on day 5, one chromosomal normal, 6AA quality embryo was implanted. We now have a 5 month-old beautiful daughter. We have two chromosomally normal 6 day frozen embryos we could use. They were classified as 4BB and 4BC in quality. I also have frozen eggs we could use, if the frozen embryos fail. In your opinion, what do I need to consider? Btw, we hope to only have one more child (I will be 42 years-old at the time of implantation (still breast-feeding, but hope to start fertility treatment when our daughter is a year old). My health is good, and last pregnancy was uncomplicated.

  • Carole Says:

    Dear 2ndbabycurious,
    I would definitely transfer any normal embryos you have, regardless of score, before I resort to frozen eggs. The embryos have proven themselves. Frozen eggs tend to have a lower fert rate and you’ll lose some in culture. Definitely use all embryos up first. Congratulations on the birth of your daughter!! and Good Luck!! Carole

  • Melissa Says:

    We’ve been through two fresh transfers. The first one resulted in a positive after transferring 3 3 day embryos. I lost this pregnancy at 20 weeks to birth defect holoprosencephaly. We had genetic testing and it was found that it was not genetic.

    Just finished 2nd fresh cycle. Transferred 3 good quality 3 day embryos. Negative result. I have 2 expanded blasts we will transfer as soon as they will let me. My question is at 39, and a history of a previous pregnancy, what are my chances of achieving a pregnancy with these 2 embryos? Since the other 3 failed, does it increase the chance that these from the same cycle are viable? Thank you very much for the help.

  • Carole Says:

    Hi Melissa,
    Your odds of pregnancy depend on a lot of factors, but one of the biggest in your age group is whether or not the remaining embryos are euploid- meaning that they have the normal number of chromosomes. If they are euploid, I’d feel pretty good about your chances. The fact that the first 2 did not take has no bearing on what the next ones transferred will do. I don’t think you can read anything into it at this point. On the plus side- your endometrium lining will likely be better prepared in the preparation for your FET compared to what was needed for the stim cycle because the hormone protocol can be optimized for the endometrium –since there is no need to push FSH to get as many eggs as possible and drive estradiol levels up too high for optimal receptivity. Good Luck!! Carole

  • Jen Says:

    Hi Carole,
    Thanks so much for such an awesome, incredibly informative blog! So great to get an “insider’s” scoop on the whole process. I am Day 4 post ER, anxiously awaiting news tomorrow morning on how my eggs have progressed. I am 40 years old, 9 eggs retrieved, 9 ICSI’d, 5 fertilized. After Day 3, all 5 were still developing, with 4 graded as “good” and 1 graded as “fair” (my clinic’s designations). My RE is saying that she expects 50% to make it to blastocyst. Her strategy is to biopsy and freeze all that are still “good” by tomorrow, but transfer up to two if they are “fair” or “poor” and wait for day 6 for any remaining. My question is this – if there is only one that makes it and is “good” enough for biopsy/PGS, is it more advisable to PGS and freeze, or transfer immediately? Thanks for your advice!

  • Carole Says:

    Hi Jen,
    At 40 years of age, you have an increased risk of having embryos that are aneuploid- meaning that they have an abnormal number of chromosomes. Aneuploid embryos either don’t implant at all, implant and then miscarry, or implant and lead to some abnormalities as in Downs Syndrome. It depends on your appetite for risk. I have a very low appetite for risk and if I were a patient, I would prefer to only transfer embryos that have been tested as euploid (normal number of chromosomes). Other patients may be okay with the increased risks of transferring embryos that might be abnormal. If the lab is good at what they do, there should be little to no deleterious effect of biopsy, then freezing using vitrification, pending the PGS testing outcome on the biopsied material. The real issue for me is the testing status at transfer- I’d want to know that I was transferring only normal embryos. Good Luck with whatever you decide! Carole

  • Jen Says:

    Hi Carole,

    Thank you so much for your response! It is very comforting to get the sage advice of someone with so much experience. We ended up with 2 embryos that made it to blastocyst on Day 5, which were “good” enough for biopsy and freeze. We waited one more day for 1 of the other two that had potential to keep developing from morula to blastocyst — unfortunately, it (and the other one) arrested on Day 6 and were discarded. We were feeling pretty confident with the 2 that were frozen, but unfortunately the PGS results came back and both were aneuploidy (one had monosomy 15 and trisomy 22 and the other had monosomy 2). Needless to say, we are devastated. My RE, however, is encouraging us to try again. I’ll admit, however, that it’s hard to have faith given that even the “best” of my batch were abnormal. Is aneuploidy in all embryos fairly common? I’m assuming that’s why not all 9 eggs fertilized and/or made it to Day 5. Or is there a potential that there is an issue with the sperm? I used an anonymous sperm donor, but I assumed that anonymous sperm had the highest success rates. Thank you so much in advance!

  • Carole Says:

    Hi Jen,
    Unfortunately, at 40 years of age, I would totally expect the aneuploidy results you experienced. If you have good insurance or the financial cost of IVF is not burdensome to you, you could try more IVF but I wouldn’t expect the results to be that different. What you have learned from this cycle is that IVF is not very efficient for you. Every IVF cycle to be worth it, should generate at least 1-2 normal embryos to transfer and 1-2 to freeze, minimum. It is easier for doctors- who are human beings after all- to peddle hope and optimism, rather than tell you the difficult truth that IVF is not an investment in family building with a eventual payoff if you just perservere, but rather a high stakes gamble, given your age. You should do whatever you can afford to do and whatever you need to do to move on. You may get lucky but the odds are not in your favor. It might be time to consider all your options for family building and see what makes the most sense- given the information you now have on how the next IVF cycle is likely to go. I wish you all the best in whatever path you decide!!! Carole

  • Aa Says:

    I am terrified now, reading your last post. I will be 39 in 2 months. Just did a FET two weeks ago. Had 8 eggs taken out. 7 matured. 6 fertilized. Only had 2 embryos frozen after the 5 days at blastocyte. On transfer day only 1 contracted/ expanded correctly and was transferred. (After layer was lasered for being too thick) Pregnancy test +positive 11 days later but hcg level 22. Two days later 14. Miscarried. Today dr explained that the embryos didnt have enough energy to grow well. I recall the one transferred may have only been 10 cells? Dr says to gain weight. I am 114 lbs, says to gain 3-4 lbs. to provide more energy. Thoughts? Also worried about not having tested aneuploidy? Chromosomes. At least i dont know if clinic did. Concerned about comments above 1.you should generate 1-2 normal emb to transfer + 1-2 to freeze??? Yikes! And 2. With my age worry about chromosome testing? Thank you

  • Aa Says:

    P.s.i am hypothyroid but am controlled. Dr suggests maybe prescription too high because he feels I am too skinny (5’6″ height)

  • Carole Says:

    Hi Aa,
    I would get a second opinion regarding a need to gain weight to give more energy to your eggs. That sounds stupid. Energy from eggs comes form an organelle called mitochondria which are the “power houses” for all cells. There is research to suggest that in older women, mitochondria are less effective, and that may have something to do with the faltering progression of older embryos. Here is a lay article on that topic: http://www.huffingtonpost.com/2015/03/24/womens-aging-eggs-rejuvenated_n_6930530.html I have written about Ovascience before- there doesn’t seem to be the short path to implementation (clinical trials have been postponed or perhaps ineffective?) so I am no longer as hopeful for this idea. I think aneuploidy testing is a good idea if you plan to do more IVF cycles. It will give you more information about the embryos you are thinking of transferring- although you may find that you have few or no embryos that are normal and available to transfer. Miscarriages are almost always due to aneuploidy in embryos. At your age, however, unless you have endless financial and emotional reserves, I would caution you against doing many more IVF cycles. You are learning that IVF is not a very effective method for family building for you. It may be time to start to consider other options. I wish you much good luck for whatever path you choose going forward! Carole

  • Kara Says:

    Hi Carole,

    Thanks for maintaining such an informative site. There really is nothing else like it that I’ve found.

    On July 27, I transferred one euploid blastocyst. This embryo had been previously frozen after I underwent a fresh transfer in 2014. I got pregnant that cycle but lost the baby at 17 weeks due to trisomy 21, which is why we decided to thaw, biopsy and refreeze this current embryo before transfer on 7/27. I know this isn’t the ideal way to go about things – I understand it’s a lot for the embryo. On transfer day, however, I was told that the embryo thawed well and everything looked good. Honestly I was afraid to ask more questions (about grading etc).

    I started testing early at home and got negative home pregnancy tests from 4dp5dt through 7dp5dt. It’s taken quite a toll on me so I’ve decided to stop testing and just wait for my beta (this Friday, Aug 7).

    Do you think I have a chance? I was really banking on success given that this embryo had been tested, but I understand that at 7dp5dt I should have enough HCG in my system to register positive on a test. Could the double freeze & thaw have caused issues? Is it possible that biopsied embryos take longer to implant?

    Thanks so much


  • Carole Says:

    Hi Kara,
    I think you did everything right to try to ensure a healthy pregnancy. I don’t know how it will turn out. Home pregnancy tests are much better than they used to be but are not absolute- it is a good idea to just wait until the clinical lab test. (Hard to do- I Know!) We like to minimize what we put embryos through- of course- but they are pretty resilient so I think you still have a chance!! Wishing you Much Good Luck!! Carole

  • indus Says:

    Hello Carole,
    Conderning embryo quality, what would make embryos stop developing after day 3?
    Me (29) normal health and weight, no issues found.
    Husband (31): very low sperm count (>5mil with 0% normal morphology). Normal weight, we eat healthy, exercise, don’t drink and take tons of supplements.
    Last year we had 2 failed ICSI-treatments.
    Both treatments were identical, first 1 with Gonal F. Around 25 eggs, no transfer due to possible OHSS, good quality embryos on day 3. Then nothing to freeze at day 5.
    2nd treatment was with Menopur but similar in outcome.
    Then we changed clinics and had again the Menopur protocol but at a very low dose this. Again 17 eggs of which 9 mature.
    I did have a transfer this time of 2 top quality 11-cells on day 3. This ended in a BFN and we had again nothing to freeze.
    We are being advised donor eggs as it seems that embryo quality is solely determined by the egg quality at retrieval.
    In your experience, does it make sense? What makes the embryo quality so poor after day 3? Why does everything goes well until the compaction right before blastocyst formation?


  • Carole Says:

    HI Indus,
    I am sorry that you are having such a hard time. The fertilized egg is still using maternal RNA transcripts through day 3. Sometime on day 3 to day 4, the new embryo starts to rely on its own transcripts (from it’s newly created genome from egg and sperm) and this can cause it to fail if there are some chromosomal abnormalities or energy deficits in the embryo. Another blog post written by Dr. Malpani explains this and other reasons for embryo progression failures rather well : http://blog.drmalpani.com/2013/04/why-do-some-embryos-stop-growing-in-ivf.html.
    Actually, some would argue that 11 cells on day 3 is not a good sign because they should be starting to compact and not be distinguishable as 11 separate cells on day 3. But we have all transferred these embryos, especially if that is all the patient has but few would characterize this as ideal. Even though you are young, these past cycles are probably predictive of future cycles. I would review the list of supplements you are taking with your physician. My previous post looks at whether there is evidence that supplements for sperm improvement actually work: http://fertilitylabinsider.com/2015/01/can-supplements-really-improve-sperm-quality/ The FDA does not regulate supplements in any rigorous way- they rely on the manufacturer to test whether it works, is pure etc. http://www.fda.gov/Food/DietarySupplements/ The FDA is responsible for taking action against any adulterated or misbranded dietary supplement product after it reaches the market- not before. So just because you can buy a supplement, it does not necessarily follow that it is safe or effective- or that there are not detrimental interactions going on between supplements and other medications you are taking. It may be time to consider other paths to parenthood — you might discuss the option of donor sperm with yoru doctor. Using donor sperm is a much less expensive option than donor egg. Embryo quality is also dependent on sperm quality and with 0% normal sperm morphology, this could well be the explanation for poor embryonic activation on day 3. Good Luck with whatever you decide!! Carole

  • rainbow Says:


    I have 2 donor embryos:6BB(Girl) and 6BC(boy). What are the chances to have a boy with 6BC?


  • Zuza Says:

    Hello Carole,

    First of all, thank you for all the precious information here!

    I have a question about the possible timing of implantation for blastocyst 2BA.
    I had transfer on 11/24 (medicated FET)
    6 days after transfer, B-hCG was 2.69, E2 1517 and P4 38.4 Later the same day I started to bleed and by the evening it turned to just spoting and for the second day. Now seems fine. Is it possible that 5days blast 2BA implanted 6 days after transfer causing this blood? –
    I am wondering about the timing of events … if this blood was from implantation, shouldn’t beta show after 48 hours versus just before the bleeding?
    I was also taking Baby Aspirin and Clexane. Now the clinic told me to stop but mayby this influensed this bleeding… so many raicing thoughts! I just hope there is still a chance.

    Thank you,

  • Carole Says:

    Hi Zuzu,
    These questions regarding bleeding are more medical in nature and should be addressed with your doctor. Yes, a little bleeding is sometimes observed with implantation. You’ll need to discuss the details with your doctor since they have the complete picture. Yes, there is always a chance. Good Luck! Carole

  • Zuza Says:

    Hello Carole,

    Thank you for your response. My doctor thought it was implantation bleeding … but now unfortunately, beta dropped again so we are planing the next round.

    We are concidering transfer of two 5 days blastocysts next time: 1AA and 1BB. Is there a way to tell their hipothetical timing of further development? – I know that #1 means “early” versus # 6 which would already be hatching… so my analytical mind is wondering when our # 1s would get to the stage when implantation could begin- next day after transfer or after 3 or more days?

    We need to travel for transfer to Europe (12hours on the plane with all the radiation, changes of pressure etc.) Last time we flew back 4 days after transfer.
    What would be the safest time to travel back: right after transfer while the embryo is still protected by its shell or after implantation is confirmed?( so I would have to stay over a week after transfer?). There is not much within our control but if I can help those embies with better planing of the trip …

    Thank you again,

  • Carole Says:

    Hi Zuza,
    Your doctor will coincide the phase of your endometrium with the window of implantation to match your embryo. The window of implantation is between 3-5 days so there is some flexibility there. In theory, your embryo should be fine inside the uterus, in either the hatched or unhatched phase. If you are anxious about flying right away, you might wait a few days if you have that option for your peace of mind. I don’t think there is any consistent medical guidance on this issue, but if you feel good about your choice, you might be just a wee bit less stressed, which might be helpful. Good Luck!! Carole

  • Zuza Says:

    Hi Carole,
    Thank you.
    I was just worried because my clinic always tells me to start progesteron 5 days before the transfer – no matter if the embryo was graded 5 or 1. But now I understand that there is a window…
    Thank you,

  • YashIVF Says:

    Thanks for sharing this informational blog post with us.

  • Lily Says:

    Hi,I just had ET on the 11/04 and my doctor was a bit concerned about my thick lining and it was 16 on day 12 and I had 5 more days before ET.Is it possible that it will implant?thank you

  • Naz Says:

    Hi Carol,

    My husband and I had ICSI due to a failed vasectomy reverse. Our first fresh cycle out of 11 mature eggs 3 fertilised and almost 1 made it to day 5 at early stage of blast. we put it back but it didn’t implant. Our second cyle, 9 eggs and 5 fertilised with fresh sperm retrieval this time. Out of which we have two day 5 embryos (4AB and 3BB) and one day 6 embryo (4BB). Our consulted we advised that we freeze tem this time as both time I has high Estrogen 17000 and 20000. He wants to put them bak in 2 months time.
    Now my qustion is: 1) could the reason for poor the number of fertilisation be Surgical Sperm Retrival and the quality of the sperm? Or could it be my age or poor egg qulity or abnormal Chromosome? I do not have this case in the history of my family.
    FYI, I was not on high dose of medication (150 IU of Menopur) as it seems I responded quickly to it. The lining was about 13mm as well. I had never tried for a baby up to now. My husband had children before his vasectomy13 years ago. I’m 37 and he is 43.
    2) Which one of these embyos would you advise to be transfered?
    Thank you in advance

  • Carole Says:

    HI naz,
    You ask very good questions. Unfortunately, any of the issues you raise could explain the relatively poor fertilization rate but the more important –and good –thing is that you have several blastocyst stage embryos. I’d probably start with the 4AB embryo, then the second day 5 embryo. But I would be hopeful because you have 3 embryos that all reached blastocyst stage- that is a very good sign. Good Luck!!

  • melania Says:

    I had a retrieval done with 25 eggs, 18 fertilized and 6 made it to day 5 and were sent out for PGD. Two of the four embryos were 5AA and 4BB, the day of the transfer I was told the 5AA had turned into a 6AD and would not survive and we implanted the 4BB but got a negative pregnancy test. I am 36 y/o relatively healthy. Why would such a “strong” embryo degrade upon thawing? Now I have 2 embryos frozen, a 4BC and 5CA, would it be best to transfer those two or do another retrieval cycle?

  • Anne Says:

    Hi Carol- I have long been visiting your website. It is incredibly factual, and you write on a complicated topic in a way that we can understand. Thank you so much.
    I have a couple questions for you, if you have time:
    1. In the first part of your article, you write that there is a weak correlation between appearance and implantation success. This is an incredibly reassuring comment. I went through IVF in 2014 at age 31 and “over performed,” resulting in 7 blastocysts. We transferred two, one of which had my fertility clinic embryologist excited, which my RE said was rare 🙂 One embryo took, and while I can’t be certain which, I suspect it was the looker that became my son. The five remaining blastocysts are now frozen – I don’t know their grades, but I do know my embryologist was not as excited about their appearance. If I understand your comment above, it sounds as if their appearance may not really matter- that I still have a chance one of the remaining five could be viable despite not being a supermodel of an embryo.

    I am currently in the midst of a miscarriage which has been heartbreaking, as this conception was completely unexpected and without medical intervention. I am grieving but eager to return to my fertility clinic. I did not test my embryos for chromosomal normality, but it sounds like based on the above, the “functionality” is good. As an embryologist, would you suspect that one of my five “ugly” blasts would survive the thaw and turn into a rainbow baby? I know there are many factors and my diagnosis is “unexplained.” But after this loss, I am eager to be pregnant again. I had formerly seen a research article that seemed to indicate that with respect to ivf, usually only one or two eggs out of the cohort are viable and turn into children. I’ll try to link it. Kindest regards. Anne

  • Anne Says:

    There should have been a 2 in front of my second paragraph sorry! Here is the article http://www.rbmojournal.com/article/S1472-6483(13)00530-0/abstract

    I’m not really sure how to make sense of its application to my situation, but it would seem to indicate that because my cycle resulted in a successful pregnancy (which I am very thankful for and don’t want to sound “greedy” for wanting another when I know what it is like to long for a single baby), that perhaps my remaining frozen embryos have a diminished chance of resulting in a live birth 🙁 thank you for your wisdom and insight. – Anne

  • Carole Says:

    Hi Melania,
    I am sorry you had such a disappointing result! So it is not clear if thawing is the culprit. Problems with freezing or the biopsy procedure can also cause issues for embryos. I wrote a previous post on the grading scale and what it means in terms of pregnancy chances which might be useful: http://fertilitylabinsider.com/2011/12/understanding-the-gardner-blastocyst-grading-scale/

    Also, I would definitely ask your doctor what their experience is when they transfer 4BC and 5CA embryos? The issue with both embryos is that the inner cell mass is less than ideal in that there relatively few cells -which are the “starter cells” for the embryo. If you are going to a US clinic, you can check the pregnancy rates of your current clinic against the overall US rate at http://www.sart.org. Make sure the clinic you are using is better than the US average. Good luck!!! Carole

  • Carole Says:

    Hi Anne,
    I am so sorry that you are going through a miscarriage. When you are ready and the doctor gives you a green light- I think you can probably be hopeful about your remaining embryos since based on your age (31) you are at not at particularly high risk for aneuploid embryos and they reached blastocyst stage which is a positive functional indicator. I wish you MUCH GOOD LUCK going forward!! Carole

  • Johanna HH Says:

    I just came across this site and I find so informational Thank You!
    My question is this, Im currently 36 with 4 children, my first at 16yo last at 25, never had any issues getting pregnant. Had a partial hysterectomy with my last pregnancy due to placenta previa, and increta. My husband is 33 and has 1 child. Neither of us have any genetic problems and we did a genetic counseling session as well. We are trying for our own, i have since done 2 rounds of IVF with ICSI at age 36. First round I got 18 eggs, 13 fertilized, 5 made it to blastocyst. After PGS we got Monosomy 19, 4, 21 and Trisomy 22 and one normal embryo. On our second cycle (2 months after our first retrieval) we got 9 eggs, 7 fertilized and only 1 made it to blastocyst stage. It was graded a XBBB or 4BB. We were so scared to do pgs because its so expensive to do for 1 embryo and I was scared of an abnormal result to be honest. Also I felt that the grade was pretty good to take the risk. Now we are using a surrogate and my question is, what are my chances that both will implant and be a successful healthy pregancy and babies. We really want twins and only have these 2 embryos.
    Thanks in advance!

  • Carole Says:

    Hi Johanna,
    I am sorry you are having such a difficult time. There are likely some genetic issues at work here if you have great fertilization (18!), good embryo development (5 to blast) and yet only 1 of 5 embryos is normal. What some people do to save money on PGS is to repeat IVF several times, freezing the embryos after biopsy, pooling all the embryos and sending samples from 3 IVFs off at the same time for testing. If it were me, I would only transfer the one that tested normal with the surrogate. That is your best bet. I would caution you against twins. It is not the ideal obstetrical situation. IF you transfer two and one is an abnormal embryo, it might not fail until later in pregnancy and then you put both your normal and abnormal fetuses at risk. But I would discuss in detail with both a genetic counselor and obstetrician if possible. Good luck with whatever you decide! Carole

  • Megan Says:

    Hi, and thanks for making your expertise available!
    I’m 38, with good AMH and great AFC, pursuing IVF thanks to my husband’s poor count, motility, and morphology. We’ve now done three cycles, transferred a total of 5 6AA or 5AA embryos that were PGS tested to be euploid, and haven’t had a single positive hCG test. I’ve had every test under the sun, with no identifiable uterine issues. The first two stim cycles yielded decent numbers of oocytes (11 and 14) with most eggs mature, most fertilizing with ICSI, about half making it to blast, and about half of those PGS-normal. The last cycle was lower yield (8 oocytes) with only three making it to blast, and all 3 had monosomies on PGS. While it sounds like the reliability of PGS is being brought into question, it still seems wise to continue this given our ages.
    We’re fortunate to have the financial resources to keep trying, but this process is taking an enormous emotional toll on me especially. I’m eager to try something different, because obviously I want a different result.
    Question is this: what should we change?
    -Egg donor? I know I’m old, but it seems unlikely that poor quality eggs could be generating all these good-quality embryos (I understand that some will be aneuploidy because of my age)
    -Uterine issues? Could there be something wrong that has escaped notice on countless biopsies, SIS, and hysteroscopy?
    -Sperm issues? Since we already know the sperm quality is poor, is it possible that it’s still preventing implantation even though we’re theoretically bypassing it with ICSI?

    I’m miserable, regretting the years I spent focusing on a career, and don’t want to waste any more time if IVF is destined to continued failure for us. I don’t see a point to continuing to do something that has had only negative, devastating results. But I don’t know what to change to get a different result.
    Any ideas? I appreciate your time and expertise!!

  • Carole Says:

    Hi Megan,
    I am sorry that you are having such a hard time. I wish I could tell you the one thing that technology hasn’t provided to you already that could make a difference. It might just be a numbers game and if you keep doing IVF, one of your normal blasts could implant and work out. The question is, how many years do you want to spend on the uncertainty, emotional turmoil and financial drain? At some point, it’s not worth it. You need to find that balnace point where IVF doesn’t make sense anymore and consider a “sure thing” like adoption. Since implantation seems to be the issue even with normal blasts, I hesitate to suggest donor egg or donor embryo. Uterine implantation is not as well understood as fertilization and I am not convinced we are able to diagnose everything that can go wrong. If i was in your shoes, I think I might say, I am done with this crap. I know there are children out there who need someone like me and I am tired of waiting for a miracle or a lucky roll of the dice. You might not be there yet and so may want to try a few more rolls of the dice with IVF, but it might be time to at least consider other options that will make you a mother, guaranteed. Good Luck with whatever you decide! There are many paths to parenthood. You will find one that works for you or decide there are many other meaningful things you can do in your life. There are no wrong or right choices- just what works for you and your partner. Good Luck!! Carole

  • Susan Says:

    Dear Carole,
    Thank you for sharing your advice and expertise on this site. I am 42 (general good health). My husband (43) and I have been unsuccessful with IVF treatments for 4 years, we tried 1 unsuccessful egg donor process, and we are now trying an embryo donation. We have been given a profile for a 6AA embryo, PDG tested, which I think is good. However, the donor mother (26yr old) has been diagnosed with PCOS and the father (34) has a history of cancer in his family – (sister, mother, father, grandmother.) Is it possible that a high quality embryo (6AA) may minimize the chances of these illnesses being passed on to the offspring? I would like to move forward however, I am concerned with the possibility of the child having health issues early in life.

  • Carole Says:

    Hi Susan.
    The scoring takes into account the appearance of the embryos at specific stages of development which not tightly correlated to genetic normality. We routinely grew lovely blasts that were derived from spontaneously derived abnormally fertilized eggs (with patient permission for technical training). I think you should discuss your concerns with a genetic counselor- the embryo scoring really won’t give you much insight. Good Luck! Carole

  • Kate Says:

    Hi Carole,
    I’m hoping I can ask you a question, although you posted this so long ago. I’m healthy and have been told my fertility is good. I did just turn 35, though. My husband has azoospermia. We don’t know why. His brother has it too. They both tested negative for everything. After taking Clomid, he started producing sperm (about 500,000 total). Our first IVF/ICSI cycle we got 14 mature eggs, 7 fertilized, 3 made it to blast, and two were PGS normal. We decided to bank more embryos. Our second cycle we had 18 mature eggs, 15 fertilized, 10 made it to blast… and then 2 PGS normal again. This was shocking as we expected more embryos. My doctor is pleased with our results. I’m trying to be hopeful, but feel very afraid that our “normal” embryos have issues. My nurse says “normal is normal” and the fact that we had 80% abnormal (due to the sperm) our second cycle doesn’t mean the normals will have issues. She also says the grading is good, and one is even an A. Still, I’m freaked out! What do you think are our chances that one of these embryos gives us a baby? I know that’s probably impossible to say, but wanted to see if you have any insight. Thank you in advance if you’re able to answer my question!!!

  • megan Says:

    Hi Carol,
    I went through egg retrieval a couple weeks ago and waiting for my PGS results on 5 embryos. I am currently 32 years old (33 in a month). What is the % that they could come back abnormal for my age? I should find out this week and going crazy.

    I have a healthy 2 year old son at home which we conceived via fertility treatments & IUI. My issue is that i don’t ovulate.

    The embryos that went to PGS are:
    Embryologist graded them fair (3) to good (2).
    Just so nervous!!

  • Carole Says:

    HI Kate,
    I think you should feel positive about the two normal by PGS embryos. Normal chromosomal status is the biggest positive an embryo can have and is much more predictive that appearance. You probably have your pregnancy test result already or soon–Good Luck!! Carole

  • Carole Says:

    HI Megan,
    Keep in mind you are still under 35 (positive indicator) and you have a son already (proven fertility) so you are in great shape. PGS will allow you to not transfer any that are abnormal (third positive indicator) so although there are never any guarantees, you are in a much better position that many people. Good Luck!! Carole

  • Lanee Says:

    Hi Carole,

    I’m 38, using donor sperm due to Hubby having NOA. Due to my age, my doctor suggested PGS which I do want to proceed with. But over 2 cycles, the embryologist has told me the embryos were not able to be biopsied on day 5 (first cycle, only 1 embryo was a morula on day 5; 2nd cycle, 1 embryo was an early blast, 1 starting to form a blast & 1 morula). Each time, they have waited to day 6 but no embryos were able to be tested as they all stopped progressing by day 6. This really worries me that my embryos don’t seem to be able to get to the right stage by day 5.

    Instead, my doctor wants to freeze on day 5 for my next cycle as she said the embryos from my first 2 cycles may have been frozen in day 5 & transferred even though they may not be good enough for PGS. She said that pushing them to day 6 in the lab doesn’t seem to work for me. In your opinion, if an embryo can not survive to day 6 in the lab, is there any chance for it to be a successful pregnancy if we did a day 5 transfer instead with a morula/early blast? I’m worried that even if we do a day 5 transfer, if the embryo can’t survive go day 6 in the lab, it means there wouldn’t be a successful pregnancy either so the doctor is just telling me to do this so she can say she managed to “transfer” something (since I’ve never made it to transfer before)

    What is the minimum level of progress of an embryo before you can successfully freeze on day 5?

    Thanks so much for your advice and thoughts on this.

  • Carole Says:

    Hi Lanee,
    You might be better off with a day 5 embryo, even if it is just barely a blastocyst. It varies by the clinic. In my lab, we did better with day 5 blastocyst transfers compared to day 6 blastocyst transfers. We also had pregnancies with transfer of morulas. I would be concerned if the embryo stops advancing and stays at one stage for an extended period- more than a day. The blastocysts doesn’t need a huge fluid -filled space to be freezable as a blastocusts. You can actually freeze all stages of development from fertilized egg to blastocyst stage, but clinics develop preferences for vitrifying at certain stages. I would definitely try an earlier day 5 transfer even if it is closer to morula or early blast stage. Good Luck!! Carole

  • Harry Says:

    Hi Carol,

    This is such an informative site. Thank you for sharing.

    In your opinion do you think a fresh transfer is better than a FET or do both provide the same results?

    I finished my 5th IVF cycle. 11 eggs retrieved, only 4 mature and 3 fertilized. 1 made it to Day 5 and is a 4BB grade. We froze this embryo in a hope of collecting few more embryos. I am currently 32. My biggest problem has been immature eggs. In all the IVFs more than 60% of the eggs are immature.

    Both my partner and me have been tested and all results hav come back normal.

    Would you know the reason for so many immature eggs? We have tried different protocols, sometimes used two different trigger shots to help with the maturity issue but still dont find success.

    Any insight into this is appreciated. Thank you for your time.

  • Carole Says:

    Hi Harry,
    Both fresh and frozen transfers can be equally successful, now that vitrification and warming of embryos is the preferred method. In the old times, slow freezing methods resulted in loss of some cells from the embryos at every thaw. Vitrification, done correctly, preserves all the cells and embryos tolerate it well. The other issue which varies with fresh and frozen embryos is the readiness of the uterine lining. For a frozen transfer, all the effort is to optimize the hormonal conditions for implantation. In a fresh cycle, the stim cycle has to accomplish maturation of a large number of eggs AND also support the endometrium lining which is trickier since the high estrogen/progesterone ratio needed for stim is not the best for the endometrium. It still works most of the time for fresh cycles but it is a bit trickier. As far as the stim cycle goes, that is a better question for your physician. Clearly, egg maturation and the stim cycle are closely linked and your physician can best address that. Wishing you MUCH GOOD LUCK!! Best Wishes, Carole

  • laila Says:

    Hi Carol,

    Your website is very informative. Thanks very much.

    I did IVF when I was 28 and it resulted in 11 good grade embryos. The fresh transfer resulted in my lovely son and the first FET was a chemical pregnancy. I transferred two embryos the next round and one took which is my youngest son.

    We decided to try for a third but this time I was hoping to do PGS and try for girl. I shipped my embryos down to the US and they thawed the remaining 7. They said 4 survived the thaw and tested and I had three normal two girls and one boy. I transferred the girl which was 4AA but it was chemical pregnancy.

    The refroze the other two embryos and recommended that I transfer the other girl. I am super worried about refreezing.

    What is your experience with embryos that are refrozen? does the quality matter?


  • sukhi Says:

    Hi Carol,
    I am turning 36 this month and no medical problems. TTC for 3 months, 3-4 unsuccessful cycles with clomid, 1 unsuccessful IUI.
    I have low AMH of 4.27. We did egg retrieval last month. 4 mature eggs, 3 fertilized and only 1 3BB day 5 blastocyst. We didn’t do PGS.
    I never conceived before. Going to get Frozen blastocyst 3BB transfer next month. What are my chances to get pregnant.

    Please advice. We will appreciate your reply.

  • Carole Says:

    HI Laila,
    If vitrification was the method used for freezing, the embryo can tolerate freezing, even a couple of times. It is probably worth another transfer attempt. Good Luck!! Carole

  • Carole Says:

    HI Sukhi,
    I can’t give you a prediction but I will say it’s always good to have a blastocyst to transfer. You can ask your physician to estimate your chances by asking him/her how well women of your age with similar diagnostic barriers to conception do in their clinic. But remember, no matter the probability, it takes one healthy embryo to encounter an implantation ready uterus and you can be pregnant. Good Luck!! Carole

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